Original Article
Teledermatology in Air Force: Our Experience Wg Cdr R Rajagopal*, Lt Col A Sood+, Wg Cdr S Arora# Abstract Background: Teledermatology is the science of telemedicine applied to the field of dermatology, with an aim to avoid travelling to nearest specialist facility. Methods: Patients from Air Force Stations Jaisalmer, Naliya, 5 Air Force Hospital, Jorhat and 9 Air Force Hospital, Halwara were consulted by the dermatologist at Command Hospital (Air Force) Bangalore through the telemedicine network provided by ISRO, Bangalore from March 06 to May 08. Result: 115 patients underwent teledermatology consultation using virtual teleconference (VTC) and this was compared with Store and Forward (S and F) consultation at all four stations as well as Face to Face (FTF) consultation at 5 Air Force Hospital Jorhat. Diagnosis concordance was 52.5% and 53% for Jorhat and Halwara for VTC vs S and F, while it was 75% and 25% for Jaisalmer and Naliya. For VTC vs FTF, the concordance improved to 60.66% and for S and F vs FTF it improved to 91.8%. Concordance was better for localized lesions than for generalized lesions especially of the papulosquamous group of disorders. Another reason for the discordance with VTC was poor resolution of cameras at the peripheral units. Conclusion: Teledermatology is useful for patient care in the absence of local specialist cover and the patients have to travel long distances resulting in loss of manhours. However, better camera resolution at peripheral centres will result in greater concordance. MJAFI 2009; 65 : 342-346 Key Words : Teledermatology; Virtual teleconference; Store and forward; Face to face
Introduction elemedicine 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. 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 an increased interest in this field [1]. Dermatology being a visually oriented specialty, lends itself well to telemedicine [2]. The term “teledermatology” was introduced in 1995 by Peredenia and Brown who described teledermatology project in vast rural areas in Oregon (USA) where dermatologic care at the time was supplied only by two local dermatologists [3]. Dermatologists have relied upon imagery as an integral component of their practice since its evolution as a distinct specialty. As the imaging techniques improved and cost of imaging devices and accessing Internet fell, it is only natural that patients, primary care providers and dermatologists alike explored this communication medium for their use.
T
Material and Methods The patients were referred by the medical officers located
at Jorhat, Nalia, Jaisalmer and Halwara. The telemedicine system provided by ISRO linked these stations with Command Hospital (Air Force) Bangalore. The patients included serving personnel, ex-servicemen and their dependents. Virtual teleconferencing (VTC) as well as Store and Forward (S and F) consultations were used. Virtual Teleconference mode and Store and Forward mode were applicable to Jaisalmer, Halwara and Naliya, whereas Jorhat had in addition to these modes, a FTF (Face to Face) consultation also, since a dermatologist was available at 5 Air Force Hospital. Digital images of the patients consulted on VTC mode were sent on webmail for evaluation by S and F method and the same patients at Jorhat were evaluated with FTF consultation by the dermatologist. Written consent for sending images was taken by referring individuals. Where face was being imaged, eyes were blocked to avoid identification. Also patients were explained that teledermatology consult may not equal a FTF consultation and there may be diagnostic inaccuracies. Informed consent on these issues was also obtained. The equipment used for telemedicine was provided by ISRO Bangalore, which consisted of a 21” TV, a Sony PCS camera with resolution of 800 x 600 pixels and computer peripherals. At the client site in the peripheral units, client hardware and software was installed by ISRO. However, the cameras at the periphery were web cameras. We used utility, efficacy, satisfaction and treatment outcome scales for data analysis (Tables 1-4).
Professor (Dermatology & Venerology), Command Hospital (Air Force) Bangalore. +Classified Specialist (Dermatology & Venerology) MH, Agra Cantt. #Classified Specialist (Dermatology & Venerology), 7 Air Force Hospital, Kanpur-208004.
*
Received : 20.12.08; Accepted : 12.08.09
E-mail : [email protected]
Teledermatology in Air Force
343
Results A total of 115 patients underwent teledermatological consultation from March 06 to March 08 with four stations located at Jorhat, Jaisalmer, Naliya and Halwara. Maximum numbers of cases (43) were in the 21-30 year age group. There were 72 males and 43 females. Serving patients constituted 46 patients while dependents were 69 in number. There were 17 (14.78%) cases of psoriasis , melasma eight (6.95%) cases, alopecia seven (6.08%) cases while scabies and chronic paronychia accounted for six (5.21%) each. Papulosquamous disorders as a group constituted about 19% of cases and were most difficult to diagnose during VTC due to poor clarity of cameras. Follow up or repeat consultations were done in ten cases. Most follow ups were from Jaisalmer (five cases) and the no of follow ups was one in seven cases. Two follow ups were recorded in three cases. Connectivity profile remained variable for most part of the project period. However, efforts were made to access telemedicine centres to the extent possible. The number of days of connectivity was maximum with Jorhat (133, 29.1%) and Naliya (134, 29.38%) while that with Jaisalmer and Halwara was 77, (16.8%) and 112, (24. 56%). Connectivity existed to one place on a day as well as sometimes to two stations on any given day. The maximum teleconsults were held with Jorhat (61, 53. 04%) followed by Jaisalmer (25, 21.73%), Halwara (17, 14.78%) and Naliya (12, 10. 43%). Evaluation scales (Tables 1-4) were sent to the referring medical officers at the four stations and were returned with Table 1 Utility scale Grade
Interpretation
Frequency of use
0 1 2 3
Not being used Occasional use Moderate use Frequent use
Nil Once in a month Once a week Alternate day or daily
Table 2 Efficacy scale Grade
Interpretation
Basis
0
Not efficacious
1
Moderately efficacious
2
Very efficacious
Inconvenient, diagnosis not possible Diagnosis requires repeat consults, some patients benefited Easy to use, diagnosis in first instance
Table 3 Satisfaction scale Grade
Interpretation
Basis
0
Poor
1
Average
2
Good
3
Excellent
Incorrect diagnosis, patients preferring face to face (FTF) consultations Diagnosis requires repeat consults, some patients benefited Diagnosis in first instance in many cases, many patients benefited Ideal method, patients highly satisfied
MJAFI, Vol. 65, No. 4, 2009
evaluations as shown in Table 5. The stations most satisfied with teledermatology were Jaisalmer and Naliya. The stations which felt that the system was not that useful were Halwara and Jorhat. Concordance in Diagnosis VTC vs S and F: Diagnosis was concordant in 52.5% cases and discordant in 47.5% in case of Jorhat. For Naliya the figures were discordant in 75% and concordant in 25%. In the case of Halwara, the diagnosis was concordant in 53% of cases with discordance in 47%. Jaisalmer recorded concordance in 72% of cases and discordant in 28% (Fig. 1). VTC vs FTF (Jorhat): This comparison was done only in case of Jorhat where a specialist did FTF (Face to Face) consultation of the same cases. Diagnosis concordance was in 60.66% cases and discordant in 39.34% (Fig. 2). S and F vs FTF (Jorhat): When FTF was compared to S and F, the diagnosis was concordant in 91.8% and discordant in 8.2% cases (Fig. 3).
Discussion The two methods of teledermatology are Store and Forward (S and F) teledermatology and live Virtual teleconference (VTC) teledermatology. Each mode has its advantages and disadvantages [4,5]: Store-and-Forward (S and F) Approach Advantages z It is inexpensive. z Compared to VTC, images are much clearer. z Dermatologists can review large numbers of images to increase efficiency. z It can reduce the time from referral to diagnosis. Disadvantages z Information gaps can lead to difficulties in interpreting images. A subsequent query and reply Table 4 Treatment outcome scale Grade
Interpretation
Basis
0
Poor
1
Average
2
Good
Delay in administration of treatment, loss to follow up due to patient dissatisfaction Treatment time longer than FTF consults, good for few cases Good substitute for FTF, well accepted by patients
Table 5 Teledermatology evaluation scale report Scales Utility scale Efficacy scale Satisfaction scale Treatment outcome scale
Jorhat
Jaisalmer
Halwara
Naliya
1 1 2 1
3 2 3 2
2 1 2 1
3 2 3 2
344
Rajagopal, Sood and Arora
Fig. 3 : Concordance in diagnosis : FTF vs S&F (Jorhat) Places connected
Fig. 1 : Concordance in diagnosis (VTC vs S&F)
Fig. 2 : Concordance in diagnosis (VTC vs FTF)
z
z
might be time consuming. Psychological issues cannot be addressed, and a rapport may not be developed between patient and doctor, leading to a lesser level of patient satisfaction. Legal and security issues exist regarding the identity of the person being photographed.
Virtual teleconference (VTC) Approach Advantages z It allows collection of all required clinical information. z Any area can be examined. z It can provide an opportunity for third-party education (eg, nurse or family doctor) z Instructions to referring physician /paramedic can be carried out immediately z Good rapport can be established with patient. Disadvantages z It is as time consuming for doctors as face-to-face consultations. z Picture quality may be less than optimal. z The patient, dermatologist, and referring physician must be available at the same time. z It is not cost effective. z Some patients have an inhibition to appearing in front of a perceived live camera. This would be especially so in case of conditions involving private parts. Legal aspects : It is expected that a patient would
consent to being part of a teledermatology consultation understanding the relevant issues. These issues are: z There can be a difference of diagnostic accuracy between face to face and teledermatology examination z An image of the patient will be taken and sent to a third party and stored in a record within the hospital as well as in primary care z Teledermatology may not be a substitute for hospital consultation The patient should understand these points. Some services ask patients to sign a consent form, but the relevance of this to informed consent and its legal standing are unclear. Dermatologists may use a disclaimer in the reply to the general practitioner, which is considered good practice, but is of unclear legal weight [6]. The present study consisted of 115 patients. The preponderance of males (62.6% vs 37.4%) in the study population could be due to the fact that females are less willing or shy to appear in front of the camera, in addition to the probability of preoccupation in domestic duties and resultant difficulty in coming to telemedicine centres at appointed time. 43 (37.4%) patients belonged to the 21-30 age group , the highest in the study. Reasons could be attributed to the accessibility of telemedicine to the working population in contrast to dependents, whose time has to be synchronized with difficulty. This is despite the fact that non-serving (dependents) formed a larger part of the population (60% vs 40%). However, the number of serving patients in the same age group was 61% of the total serving population thereby accounting for the observation. In general non serving patients constituted the larger group (60% vs 40%). This may be attributed to greater incidence of dermatoses in the older and younger age groups and time available to the non serving group to come for consultation. Psoriasis was the commonest disorder with an incidence of 14.78% followed by melasma with an incidence of 6.95%. Connectivity remained similar in Jorhat (29.1%) and MJAFI, Vol. 65, No. 4, 2009
Teledermatology in Air Force
Naliya (29.38%) followed by Halwara (24.56%) and Jaisalmer (18.6%). However, case discussion was most with Jorhat (53.04%) and least with Naliya (10.05%) despite connectivity being as high with Naliya as Jorhat. This may reflect the lesser requirement from Naliya. VTC vs S and F: The diagnosis concordance rates for VTC vs S and F with Jorhat and Halwara were almost similar (52.5% and 53% respectively). The statistical analysis reveals weak concordance for both these stations. However, diagnostic concordance was significant for Jaisalmer (72% vs 28%) while discordance was significant for Naliya (75% vs 25%). This is in keeping with the incidence in other studies where the concordance widely varies between 41-95% [7]. Other reports quote a diagnostic accuracy for VTC between 54 to 80% [8]. Diagnostic agreement for S and F has been found to be 68% [9], 89% [10], 58% [11] and 48% [12]. The clarity of lesions was similar for all peripheral stations being blurred for most of the time, except for certain areas like palmoplantar lesions or lesions with contrasting colour like vitiligo. The diagnosis was most difficult for lesions on the trunk for both genders alike as the focusing was found to be very difficult. On the contrary, lesions on palms and soles could be brought close to camera and adjusted accordingly. The papulosquamous disorders like pityriasis rosea, psoriasis, lichen planus, pityriasis versicolor were most difficult to diagnose due to less contrast in the lesions vis a vis normal skin . Pak et al [13] found that papulosquamous conditions, as a category, had the lowest rate of complete agreement (59%). This is also consistent with the findings of Zelickson et al [14] who determined that eruptions were more difficult to diagnose than lesions. Although not completely clear, this lower diagnostic correlation and higher uncertainty may occur for several reasons, such as the inability to perform in-office tests (eg, potassium hydroxide preparations) or to palpate the lesions. Perhaps more important is the potential sampling error, in which the contributing or referring physicians submit images that are not representative of the patient’s true skin condition The variables which affected the discordance/ concordance rates at the various stations were as follows: (a) The referring individual: Whether the person describing the lesions on the other side was a doctor or a paramedic; Entire consults at Jorhat and few at Halwara and Naliya were of this nature as the consult was done mostly when the dermatologist at Jorhat was away on leave or temporary duty. MJAFI, Vol. 65, No. 4, 2009
345
However, clarifications were obtained from the patient on points pertaining to history/examination during live VTC in case of referral by paramedic. (b) The nature of the lesions: The concordance was higher with localized lesions and on the peripheries. Most patients from Naliya (station with the highest discordance rate) had lesions of generalized nature and which could not be properly discerned. On the other hand, Jaisalmer cases were more of a localized lesion with higher concordance. (c) The quality of cameras: The problem could also be due to poor resolution of the peripheral web cameras resulting in poor resolution of images. VTC vs FTF (Jorhat) : The concordance rates improved with FTF consultations by the specialist at Jorhat (60.66% when VTC was compared to FTF as against 52.5% when VTC was compared with S and F) as observed in other studies also [7]. The VTC mode closely resembles FTF mode in that, similar questions are asked to the patient in both modes to arrive at the diagnosis, while in SF method there is no interaction with the patient. FTF vs SF (Jorhat) : The concordance rates among these two type of consults was of a high concordance as the digital images when sent by e-mail are of very high clarity and similar diagnosis is usually arrived at in most cases, barring instances when interactive questions have to be asked from patients. Hence this reflects the high diagnostic agreement 91.8% vs 8.2%. This correlates also with other assessments in literature where accuracy of low cost store and forward (SF) dermatology was compared with that of traditional face to face (FTF) consultation by High et al [10] at Mayo clinic involving three dermatologists. A total of 106 dermatologic conditions in 92 patients were included. Concordance between FTF and SAF diagnoses was high, ranging from 81 to 89% for three dermatologists. Evaluation Scales : The highest values for the scales of efficacy, were obtained from Naliya and Jaisalmer as compared to Jorhat. The reasons could be lack of specialist facilities at these two stations as compared to Halwara and Jorhat where already Air Force Hospitals exist. In Jorhat the telemedicine was only useful when the specialist was out of station. In Halwara too, the access to medical specialist was available though a dermatologist is not available there. However, in Jaisalmer and Naliya the nearest dermatologist is 300 km away at Jodhpur. Hence the patients and referring physicians evaluated teledermatology more favourably at these locations. Economy Achieved : Significant economy was achieved by teledermatology facility in Jaisalmer where
346
Rajagopal, Sood and Arora
a patient has to undertake an overnight journey to MH Jodhpur. A total of eight serving and 17 non serving personnel consulted at Jaisalmer. In case of non serving personnel, an attendant accompanies the patient also. Hence by teledermatology at Jaisalmer an economy of Rs 10,200 (Rs 600 x17) (to and fro cost for patient and attendant) and for serving cases a saving of Rs 2400 (Rs 300 x 8) was achieved. To conclude, teledermatology is a useful tool at places where there is no specialist cover, which enables saving of manhours and mandays. However, to make it a more popular and useful tool, the quality of cameras at peripheral locations needs to be upgraded to minimum of 640 x 800 pixels to enable smaller lesions on covered areas like trunk etc to be discerned clearly. The connectivity to the peripheral stations needs to be continuous and clear at all times. Acknowledgements Gp Capt PS Murthy (Retd) for study concept, Wg Cdr S Grover as initial coworker, Dr R Rajagopal for statistical consultation and SMOs Jaisalmer, Nalia, Halwara for participation. Conflicts of Interest This study has been financed by research grants from the O/o DGAFMS, New Delhi. Intellectual Contribution of Authors Study Conceptt : Wg Cdr R Rajagopal Drafting & Manuscript Revision : Wg Cdr R Rajagopal Study Supervision : Wg Cdr R Rajagopal, Lt Col A Sood, Wg Cdr S Arora
References 1. Elizabeth MTW, Terri CM, Peter Soyer H. Teledermatology: How to start a new teaching and diagnostic era in medicine. Dermatol Clin 2008;26: 295-300.
2. Lesher JC, Loretta DS, Gourdin FW. Telemedicine evaluation of cutaneous diseases: A blinded comparative study. J Am Acad Dermatol 1998; 34:27-32. 3. Perednia DA, Brown NA. Teledermatology: one application of telemedicine. Bull Med Libr Assoc 1995; 83:42-7. 4. Watson JA, Bergman H, Kvedar CJ. Teledermatology. Available at http://www.emedicine.com/derm/topic 702.htm. Accessed 2008. 5. Feroze K. Teledermatology in India: Practical Implications. Indian J Med Sci 2008; 62:208-14. 6. British Teledermatology Society. Legal aspects of teledermatology. Available at http://www.teledermatology.co.uk/ home/legalaspects.ashx. Accessed 2009. 7. Pak H, Burg G. Store and Forward Teledermatology. Available at http://www.emedicine.com/derm/topic560.htm. Accessed Oct 30, 2008. 8. Eedy DJ, Wootton R. Teledermatology: A review. Br J Dermatol 2001; 144:696-707. 9. Whited JD, Hall RP, Simel DL, Fog ME, Stechuchak KM, Drugge RJ, et al. Reliability and accuracy of dermatologists clinic based and digital image consultations. J Am Acad Dermatol 1999; 41:693-702. 10. High WA, Houston MS, Calobrisi SD, Drage LA, McEvoy MT. Assessment of the accuracy of low cost store and forward teledermatology consultation. J Am Acad Dermatol 2000; 42:776-83. 11. Tucker WF, Lewis FM. Digital imaging: a diagnostic screening tool? Int J Dermatol 2005; 44: 479-81. 12. Mahendran R, Goodfield MJ, Sheehan-Dare RA. An evaluation of the role of store and forward teledermatology system in skin cancer diagnosis and management. Clin Exp Dermatol 2005; 30:209-14. 13. Pak H, Triplett CA, Lindquist JH, Grambow SC, Whited JD. Store-and-forward teledermatology results in similar clinical outcomes to conventional clinic-based care. J Telemed Telecare 2007; 13: 26-30. 14. Zelickson BD, Homan L. Teledermatology in the nursing home. Arch Dermatol Feb 1997; 133:171-4.
ANNOUNCEMENT BEST REFEREE AWARD : MJAFI The Best Referee Award has been instituted with effect from 2006 to appreciate the contribution made by the referees in publication of the articles in MJAFI. The award will be given during the AFMRC annually. The criteria for selection of Best Referee would be: (a)
Usage of email in all correspondence
(b)
First response within two weeks of receipt of article
(c)
Subsequent responses within one week
MJAFI, Vol. 65, No. 4, 2009
Teledermatology in Air Force: Our Experience Wg Cdr R Rajagopal*, Lt Col A Sood+, Wg Cdr S Arora# Abstract Background: Teledermatology is the science of telemedicine applied to the field of dermatology, with an aim to avoid travelling to nearest specialist facility. Methods: Patients from Air Force Stations Jaisalmer, Naliya, 5 Air Force Hospital, Jorhat and 9 Air Force Hospital, Halwara were consulted by the dermatologist at Command Hospital (Air Force) Bangalore through the telemedicine network provided by ISRO, Bangalore from March 06 to May 08. Result: 115 patients underwent teledermatology consultation using virtual teleconference (VTC) and this was compared with Store and Forward (S and F) consultation at all four stations as well as Face to Face (FTF) consultation at 5 Air Force Hospital Jorhat. Diagnosis concordance was 52.5% and 53% for Jorhat and Halwara for VTC vs S and F, while it was 75% and 25% for Jaisalmer and Naliya. For VTC vs FTF, the concordance improved to 60.66% and for S and F vs FTF it improved to 91.8%. Concordance was better for localized lesions than for generalized lesions especially of the papulosquamous group of disorders. Another reason for the discordance with VTC was poor resolution of cameras at the peripheral units. Conclusion: Teledermatology is useful for patient care in the absence of local specialist cover and the patients have to travel long distances resulting in loss of manhours. However, better camera resolution at peripheral centres will result in greater concordance. MJAFI 2009; 65 : 342-346 Key Words : Teledermatology; Virtual teleconference; Store and forward; Face to face
Introduction elemedicine 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. 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 an increased interest in this field [1]. Dermatology being a visually oriented specialty, lends itself well to telemedicine [2]. The term “teledermatology” was introduced in 1995 by Peredenia and Brown who described teledermatology project in vast rural areas in Oregon (USA) where dermatologic care at the time was supplied only by two local dermatologists [3]. Dermatologists have relied upon imagery as an integral component of their practice since its evolution as a distinct specialty. As the imaging techniques improved and cost of imaging devices and accessing Internet fell, it is only natural that patients, primary care providers and dermatologists alike explored this communication medium for their use.
T
Material and Methods The patients were referred by the medical officers located
at Jorhat, Nalia, Jaisalmer and Halwara. The telemedicine system provided by ISRO linked these stations with Command Hospital (Air Force) Bangalore. The patients included serving personnel, ex-servicemen and their dependents. Virtual teleconferencing (VTC) as well as Store and Forward (S and F) consultations were used. Virtual Teleconference mode and Store and Forward mode were applicable to Jaisalmer, Halwara and Naliya, whereas Jorhat had in addition to these modes, a FTF (Face to Face) consultation also, since a dermatologist was available at 5 Air Force Hospital. Digital images of the patients consulted on VTC mode were sent on webmail for evaluation by S and F method and the same patients at Jorhat were evaluated with FTF consultation by the dermatologist. Written consent for sending images was taken by referring individuals. Where face was being imaged, eyes were blocked to avoid identification. Also patients were explained that teledermatology consult may not equal a FTF consultation and there may be diagnostic inaccuracies. Informed consent on these issues was also obtained. The equipment used for telemedicine was provided by ISRO Bangalore, which consisted of a 21” TV, a Sony PCS camera with resolution of 800 x 600 pixels and computer peripherals. At the client site in the peripheral units, client hardware and software was installed by ISRO. However, the cameras at the periphery were web cameras. We used utility, efficacy, satisfaction and treatment outcome scales for data analysis (Tables 1-4).
Professor (Dermatology & Venerology), Command Hospital (Air Force) Bangalore. +Classified Specialist (Dermatology & Venerology) MH, Agra Cantt. #Classified Specialist (Dermatology & Venerology), 7 Air Force Hospital, Kanpur-208004.
*
Received : 20.12.08; Accepted : 12.08.09
E-mail : [email protected]
Teledermatology in Air Force
343
Results A total of 115 patients underwent teledermatological consultation from March 06 to March 08 with four stations located at Jorhat, Jaisalmer, Naliya and Halwara. Maximum numbers of cases (43) were in the 21-30 year age group. There were 72 males and 43 females. Serving patients constituted 46 patients while dependents were 69 in number. There were 17 (14.78%) cases of psoriasis , melasma eight (6.95%) cases, alopecia seven (6.08%) cases while scabies and chronic paronychia accounted for six (5.21%) each. Papulosquamous disorders as a group constituted about 19% of cases and were most difficult to diagnose during VTC due to poor clarity of cameras. Follow up or repeat consultations were done in ten cases. Most follow ups were from Jaisalmer (five cases) and the no of follow ups was one in seven cases. Two follow ups were recorded in three cases. Connectivity profile remained variable for most part of the project period. However, efforts were made to access telemedicine centres to the extent possible. The number of days of connectivity was maximum with Jorhat (133, 29.1%) and Naliya (134, 29.38%) while that with Jaisalmer and Halwara was 77, (16.8%) and 112, (24. 56%). Connectivity existed to one place on a day as well as sometimes to two stations on any given day. The maximum teleconsults were held with Jorhat (61, 53. 04%) followed by Jaisalmer (25, 21.73%), Halwara (17, 14.78%) and Naliya (12, 10. 43%). Evaluation scales (Tables 1-4) were sent to the referring medical officers at the four stations and were returned with Table 1 Utility scale Grade
Interpretation
Frequency of use
0 1 2 3
Not being used Occasional use Moderate use Frequent use
Nil Once in a month Once a week Alternate day or daily
Table 2 Efficacy scale Grade
Interpretation
Basis
0
Not efficacious
1
Moderately efficacious
2
Very efficacious
Inconvenient, diagnosis not possible Diagnosis requires repeat consults, some patients benefited Easy to use, diagnosis in first instance
Table 3 Satisfaction scale Grade
Interpretation
Basis
0
Poor
1
Average
2
Good
3
Excellent
Incorrect diagnosis, patients preferring face to face (FTF) consultations Diagnosis requires repeat consults, some patients benefited Diagnosis in first instance in many cases, many patients benefited Ideal method, patients highly satisfied
MJAFI, Vol. 65, No. 4, 2009
evaluations as shown in Table 5. The stations most satisfied with teledermatology were Jaisalmer and Naliya. The stations which felt that the system was not that useful were Halwara and Jorhat. Concordance in Diagnosis VTC vs S and F: Diagnosis was concordant in 52.5% cases and discordant in 47.5% in case of Jorhat. For Naliya the figures were discordant in 75% and concordant in 25%. In the case of Halwara, the diagnosis was concordant in 53% of cases with discordance in 47%. Jaisalmer recorded concordance in 72% of cases and discordant in 28% (Fig. 1). VTC vs FTF (Jorhat): This comparison was done only in case of Jorhat where a specialist did FTF (Face to Face) consultation of the same cases. Diagnosis concordance was in 60.66% cases and discordant in 39.34% (Fig. 2). S and F vs FTF (Jorhat): When FTF was compared to S and F, the diagnosis was concordant in 91.8% and discordant in 8.2% cases (Fig. 3).
Discussion The two methods of teledermatology are Store and Forward (S and F) teledermatology and live Virtual teleconference (VTC) teledermatology. Each mode has its advantages and disadvantages [4,5]: Store-and-Forward (S and F) Approach Advantages z It is inexpensive. z Compared to VTC, images are much clearer. z Dermatologists can review large numbers of images to increase efficiency. z It can reduce the time from referral to diagnosis. Disadvantages z Information gaps can lead to difficulties in interpreting images. A subsequent query and reply Table 4 Treatment outcome scale Grade
Interpretation
Basis
0
Poor
1
Average
2
Good
Delay in administration of treatment, loss to follow up due to patient dissatisfaction Treatment time longer than FTF consults, good for few cases Good substitute for FTF, well accepted by patients
Table 5 Teledermatology evaluation scale report Scales Utility scale Efficacy scale Satisfaction scale Treatment outcome scale
Jorhat
Jaisalmer
Halwara
Naliya
1 1 2 1
3 2 3 2
2 1 2 1
3 2 3 2
344
Rajagopal, Sood and Arora
Fig. 3 : Concordance in diagnosis : FTF vs S&F (Jorhat) Places connected
Fig. 1 : Concordance in diagnosis (VTC vs S&F)
Fig. 2 : Concordance in diagnosis (VTC vs FTF)
z
z
might be time consuming. Psychological issues cannot be addressed, and a rapport may not be developed between patient and doctor, leading to a lesser level of patient satisfaction. Legal and security issues exist regarding the identity of the person being photographed.
Virtual teleconference (VTC) Approach Advantages z It allows collection of all required clinical information. z Any area can be examined. z It can provide an opportunity for third-party education (eg, nurse or family doctor) z Instructions to referring physician /paramedic can be carried out immediately z Good rapport can be established with patient. Disadvantages z It is as time consuming for doctors as face-to-face consultations. z Picture quality may be less than optimal. z The patient, dermatologist, and referring physician must be available at the same time. z It is not cost effective. z Some patients have an inhibition to appearing in front of a perceived live camera. This would be especially so in case of conditions involving private parts. Legal aspects : It is expected that a patient would
consent to being part of a teledermatology consultation understanding the relevant issues. These issues are: z There can be a difference of diagnostic accuracy between face to face and teledermatology examination z An image of the patient will be taken and sent to a third party and stored in a record within the hospital as well as in primary care z Teledermatology may not be a substitute for hospital consultation The patient should understand these points. Some services ask patients to sign a consent form, but the relevance of this to informed consent and its legal standing are unclear. Dermatologists may use a disclaimer in the reply to the general practitioner, which is considered good practice, but is of unclear legal weight [6]. The present study consisted of 115 patients. The preponderance of males (62.6% vs 37.4%) in the study population could be due to the fact that females are less willing or shy to appear in front of the camera, in addition to the probability of preoccupation in domestic duties and resultant difficulty in coming to telemedicine centres at appointed time. 43 (37.4%) patients belonged to the 21-30 age group , the highest in the study. Reasons could be attributed to the accessibility of telemedicine to the working population in contrast to dependents, whose time has to be synchronized with difficulty. This is despite the fact that non-serving (dependents) formed a larger part of the population (60% vs 40%). However, the number of serving patients in the same age group was 61% of the total serving population thereby accounting for the observation. In general non serving patients constituted the larger group (60% vs 40%). This may be attributed to greater incidence of dermatoses in the older and younger age groups and time available to the non serving group to come for consultation. Psoriasis was the commonest disorder with an incidence of 14.78% followed by melasma with an incidence of 6.95%. Connectivity remained similar in Jorhat (29.1%) and MJAFI, Vol. 65, No. 4, 2009
Teledermatology in Air Force
Naliya (29.38%) followed by Halwara (24.56%) and Jaisalmer (18.6%). However, case discussion was most with Jorhat (53.04%) and least with Naliya (10.05%) despite connectivity being as high with Naliya as Jorhat. This may reflect the lesser requirement from Naliya. VTC vs S and F: The diagnosis concordance rates for VTC vs S and F with Jorhat and Halwara were almost similar (52.5% and 53% respectively). The statistical analysis reveals weak concordance for both these stations. However, diagnostic concordance was significant for Jaisalmer (72% vs 28%) while discordance was significant for Naliya (75% vs 25%). This is in keeping with the incidence in other studies where the concordance widely varies between 41-95% [7]. Other reports quote a diagnostic accuracy for VTC between 54 to 80% [8]. Diagnostic agreement for S and F has been found to be 68% [9], 89% [10], 58% [11] and 48% [12]. The clarity of lesions was similar for all peripheral stations being blurred for most of the time, except for certain areas like palmoplantar lesions or lesions with contrasting colour like vitiligo. The diagnosis was most difficult for lesions on the trunk for both genders alike as the focusing was found to be very difficult. On the contrary, lesions on palms and soles could be brought close to camera and adjusted accordingly. The papulosquamous disorders like pityriasis rosea, psoriasis, lichen planus, pityriasis versicolor were most difficult to diagnose due to less contrast in the lesions vis a vis normal skin . Pak et al [13] found that papulosquamous conditions, as a category, had the lowest rate of complete agreement (59%). This is also consistent with the findings of Zelickson et al [14] who determined that eruptions were more difficult to diagnose than lesions. Although not completely clear, this lower diagnostic correlation and higher uncertainty may occur for several reasons, such as the inability to perform in-office tests (eg, potassium hydroxide preparations) or to palpate the lesions. Perhaps more important is the potential sampling error, in which the contributing or referring physicians submit images that are not representative of the patient’s true skin condition The variables which affected the discordance/ concordance rates at the various stations were as follows: (a) The referring individual: Whether the person describing the lesions on the other side was a doctor or a paramedic; Entire consults at Jorhat and few at Halwara and Naliya were of this nature as the consult was done mostly when the dermatologist at Jorhat was away on leave or temporary duty. MJAFI, Vol. 65, No. 4, 2009
345
However, clarifications were obtained from the patient on points pertaining to history/examination during live VTC in case of referral by paramedic. (b) The nature of the lesions: The concordance was higher with localized lesions and on the peripheries. Most patients from Naliya (station with the highest discordance rate) had lesions of generalized nature and which could not be properly discerned. On the other hand, Jaisalmer cases were more of a localized lesion with higher concordance. (c) The quality of cameras: The problem could also be due to poor resolution of the peripheral web cameras resulting in poor resolution of images. VTC vs FTF (Jorhat) : The concordance rates improved with FTF consultations by the specialist at Jorhat (60.66% when VTC was compared to FTF as against 52.5% when VTC was compared with S and F) as observed in other studies also [7]. The VTC mode closely resembles FTF mode in that, similar questions are asked to the patient in both modes to arrive at the diagnosis, while in SF method there is no interaction with the patient. FTF vs SF (Jorhat) : The concordance rates among these two type of consults was of a high concordance as the digital images when sent by e-mail are of very high clarity and similar diagnosis is usually arrived at in most cases, barring instances when interactive questions have to be asked from patients. Hence this reflects the high diagnostic agreement 91.8% vs 8.2%. This correlates also with other assessments in literature where accuracy of low cost store and forward (SF) dermatology was compared with that of traditional face to face (FTF) consultation by High et al [10] at Mayo clinic involving three dermatologists. A total of 106 dermatologic conditions in 92 patients were included. Concordance between FTF and SAF diagnoses was high, ranging from 81 to 89% for three dermatologists. Evaluation Scales : The highest values for the scales of efficacy, were obtained from Naliya and Jaisalmer as compared to Jorhat. The reasons could be lack of specialist facilities at these two stations as compared to Halwara and Jorhat where already Air Force Hospitals exist. In Jorhat the telemedicine was only useful when the specialist was out of station. In Halwara too, the access to medical specialist was available though a dermatologist is not available there. However, in Jaisalmer and Naliya the nearest dermatologist is 300 km away at Jodhpur. Hence the patients and referring physicians evaluated teledermatology more favourably at these locations. Economy Achieved : Significant economy was achieved by teledermatology facility in Jaisalmer where
346
Rajagopal, Sood and Arora
a patient has to undertake an overnight journey to MH Jodhpur. A total of eight serving and 17 non serving personnel consulted at Jaisalmer. In case of non serving personnel, an attendant accompanies the patient also. Hence by teledermatology at Jaisalmer an economy of Rs 10,200 (Rs 600 x17) (to and fro cost for patient and attendant) and for serving cases a saving of Rs 2400 (Rs 300 x 8) was achieved. To conclude, teledermatology is a useful tool at places where there is no specialist cover, which enables saving of manhours and mandays. However, to make it a more popular and useful tool, the quality of cameras at peripheral locations needs to be upgraded to minimum of 640 x 800 pixels to enable smaller lesions on covered areas like trunk etc to be discerned clearly. The connectivity to the peripheral stations needs to be continuous and clear at all times. Acknowledgements Gp Capt PS Murthy (Retd) for study concept, Wg Cdr S Grover as initial coworker, Dr R Rajagopal for statistical consultation and SMOs Jaisalmer, Nalia, Halwara for participation. Conflicts of Interest This study has been financed by research grants from the O/o DGAFMS, New Delhi. Intellectual Contribution of Authors Study Conceptt : Wg Cdr R Rajagopal Drafting & Manuscript Revision : Wg Cdr R Rajagopal Study Supervision : Wg Cdr R Rajagopal, Lt Col A Sood, Wg Cdr S Arora
References 1. Elizabeth MTW, Terri CM, Peter Soyer H. Teledermatology: How to start a new teaching and diagnostic era in medicine. Dermatol Clin 2008;26: 295-300.
2. Lesher JC, Loretta DS, Gourdin FW. Telemedicine evaluation of cutaneous diseases: A blinded comparative study. J Am Acad Dermatol 1998; 34:27-32. 3. Perednia DA, Brown NA. Teledermatology: one application of telemedicine. Bull Med Libr Assoc 1995; 83:42-7. 4. Watson JA, Bergman H, Kvedar CJ. Teledermatology. Available at http://www.emedicine.com/derm/topic 702.htm. Accessed 2008. 5. Feroze K. Teledermatology in India: Practical Implications. Indian J Med Sci 2008; 62:208-14. 6. British Teledermatology Society. Legal aspects of teledermatology. Available at http://www.teledermatology.co.uk/ home/legalaspects.ashx. Accessed 2009. 7. Pak H, Burg G. Store and Forward Teledermatology. Available at http://www.emedicine.com/derm/topic560.htm. Accessed Oct 30, 2008. 8. Eedy DJ, Wootton R. Teledermatology: A review. Br J Dermatol 2001; 144:696-707. 9. Whited JD, Hall RP, Simel DL, Fog ME, Stechuchak KM, Drugge RJ, et al. Reliability and accuracy of dermatologists clinic based and digital image consultations. J Am Acad Dermatol 1999; 41:693-702. 10. High WA, Houston MS, Calobrisi SD, Drage LA, McEvoy MT. Assessment of the accuracy of low cost store and forward teledermatology consultation. J Am Acad Dermatol 2000; 42:776-83. 11. Tucker WF, Lewis FM. Digital imaging: a diagnostic screening tool? Int J Dermatol 2005; 44: 479-81. 12. Mahendran R, Goodfield MJ, Sheehan-Dare RA. An evaluation of the role of store and forward teledermatology system in skin cancer diagnosis and management. Clin Exp Dermatol 2005; 30:209-14. 13. Pak H, Triplett CA, Lindquist JH, Grambow SC, Whited JD. Store-and-forward teledermatology results in similar clinical outcomes to conventional clinic-based care. J Telemed Telecare 2007; 13: 26-30. 14. Zelickson BD, Homan L. Teledermatology in the nursing home. Arch Dermatol Feb 1997; 133:171-4.
ANNOUNCEMENT BEST REFEREE AWARD : MJAFI The Best Referee Award has been instituted with effect from 2006 to appreciate the contribution made by the referees in publication of the articles in MJAFI. The award will be given during the AFMRC annually. The criteria for selection of Best Referee would be: (a)
Usage of email in all correspondence
(b)
First response within two weeks of receipt of article
(c)
Subsequent responses within one week
MJAFI, Vol. 65, No. 4, 2009
