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OBJECTIVE: This report describes the design, development, and technical evaluation of a teledermatology system utilizing digital images and electronic forms captured through, stored on, and viewed through a common web server in an urban capitated delivery system. MATERIALS AND METHODS: The authors designed a system whereby a primary care physician was able to seek a dermatologic consultation electronically, provide the specialist with digital images acquired according to a standardized protocol, and review the specialist response within 2 business days of the request. The settings were two primary care practices in eastern Massachusetts that were affiliated with a large integrated delivery system. Technical evaluation of the effectiveness of the system involved 18 patients. Main outcome measures included physician and patient satisfaction and comfort and efficiency of care delivery. RESULTS: In 15 cases, the consultant dermatologist was comfortable in providing definitive diagnosis and treatment recommendations. In 3 cases, additional information (laboratory studies or more history) was requested. There were no instances where the dermatologist felt that a face-to-face visit was necessary. CONCLUSIONS: This novel approach shows promise for the delivery of specialist expertise via the internet. Cost-effectiveness studies may be necessary for more widespread implementation.

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OBJECTIVE: To investigate the diagnostic accuracy of clinicians viewing a patient's history and static digital image set compared with clinicians who conducted office-based physical examinations of the same patients. DESIGN: Observational study. SETTING AND PATIENTS: One hundred sixteen adult patients presenting with dermatologic symptoms in a university-based practice who consented to have their skin conditions documented with a still digital camera according to a standardized protocol. MAIN OUTCOME MEASURES: Concordance between office-based dermatologists' diagnoses and 2 remote clinicians' diagnoses using still digital images (resolution, 92 dots per inch) and identical medical history data to render diagnoses. RESULTS: When photographic quality was high and office-based clinician certainty was high, remote clinicians were in agreement more than 75% of the time. Office-based and remote clinicians were in agreement 61% to 64% of the time for all cases. No specific disease category appeared to be more or less amenable to diagnosis based on still digital imagery. The diagnostic certainty of the office-based clinician (reported from 0-10) had the most impact on agreement. When cases with office-based clinician certainty of no more than 7 were compared with cases with certainty of at least 9, agreement increased 54% for remote clinician 1 and 111% for remote clinician 2. As an isolated variable, photographic quality had a modest impact on agreement. CONCLUSIONS: Still digital images can substitute for the dermatologic physical examination in up to 83% of cases. This study provides validation of the store-and-forward concept of telemedicine as applied to dermatology. These results serve as the foundation for field testing of the concept in primary care settings.

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To avoid marginalization and an attendant decline in the quality of care delivered, dermatologists must take the lead in defining those services that can be delivered remotely and move aggressively to create standards of nomenclature, protocols for imaging, and methods of care delivery that can be implemented in a primary-care setting. Because of the rigorous training of its practitioners in visual analysis, it may be possible for dermatology to shift from its traditional face-to-face model to an image-based, remotely practiced one. Transition to remote practice may even be critical to the survival of the specialty. Chief among the issues in the implementation of teledermatology is whether the use of video conferencing or store-and-forward technology provides the most efficient, high-quality remote diagnosis. Ancillary issues, including image protocols, bandwidth requirements, reimbursement, licensing, liability, and patient and provider satisfaction, are important as well. These issues are discussed in a framework of capitated payment in urban, integrated delivery systems. Teledermatology has many challenges to meet before competing with face-to-face delivery of dermatologic care.

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