Introduction
The use of communications technology to facilitate the provision of health care for persons with skin disease is an area of increasing interest and activity. Following the first article on this topic in 1995, more than 240 publications have reported on active research projects from across the globe (PubMed search "teledermatology"). In 2003, a survey by the American Telemedicine Association reported 62 active teledermatology programs in 37 different US states.1
Despite this level of interest and activity, questions remain regarding how best to use the available technology and overcome the current adoption challenges, thus allowing teledermatology to become an integral element of mainstream care delivery.
The following sections address why telemedicine is a valuable resource for dermatology, the current extent of its practice, the challenges in validating teledermatology as an effective adjunct to conventional care, and the factors limiting widespread adoption.
Also see eMedicine’s Store-and-Forward Teledermatology article and Interactive Teledermatology article.
The Problem of Access
Despite previous concerns that the United States was training too many dermatologists, a workforce shortage is now evident,2 resulting in long wait times for patients. In the United States, patients with potentially urgent problems, such as pigmented changing lesions, have reported wait times as long as patients with routine problems.3 Interestingly, the number of categorical dermatology residency positions available in the United States has decreased more than 6% in the last few years.4
The problem, however, is not simply about the number of dermatologists. Both generational differences in practice and geographical distribution of doctors exacerbate the current situation. The dermatology community is clustered around urban areas, limiting access to specialists for many patients in rural locations. Of the US population, 42% is thought to live in areas underserved by dermatologists.5 Younger dermatologists have been shown to dedicate fewer hours to the practice of medical dermatology than their older counterparts.6 A 2008 study based on an American Academy of Dermatology survey from 2007 found that 29% of dermatologists spent half or more of their time practicing surgery and cosmetics combined.7 This substantial diversion from medical dermatology may lead to a contraction in supply despite a rise in the number of qualified practitioners.
An increasing proportion of patients with skin disease are being diagnosed and managed without ever seeing a dermatologist. Primary care physicians are attempting to bridge the widening gaps in the care network, despite the fact that many have no formal training in dermatology and that studies show their diagnostic concordance with trained dermatologists is only approximately 57%.8 A Scottish survey revealed that diseases of the skin or subcutaneous tissue are now the most common reason for both men and women to attend their family doctor (see iSDSCOTLAND).9 Therefore, a strong case can be made for increased collaboration between dermatologists and other health care providers in order to address high patient demand and to provide education and support.
Teledermatology - A Solution?
Consumer-grade technology has significantly altered the banking, retail, travel, and communications industries. This provides an opportunity to change the way health care is delivered. Scientific societies and governments from around the world have become increasingly interested in communication technologies and their role in providing better access to care while leading to substantial economic and social benefits.10 Whether referred to as telehealth, telemedicine, or e-health, health care communications technology offers novel means of delivering dermatological care to patients, independent of time or place, and is increasingly recognized as an important component in the modernization of the health care system.11
Dermatology has been a forerunner in the use of communications technology. As a visual specialty with low mortality and many chronic conditions, dermatology is an ideal candidate to capitalize on the unprecedented rate of technological evolution that has occurred over the last decade. Additionally, with the expensive digital cameras of the 1990s incorporated into the mobile phones of today and approximately 80% of Americans using email,12 many opportunities remain to develop innovative methods to facilitate communication between doctors and patients.
The opportunity to better use communications technology arises at a time when health care consumers are demanding the same level of convenience, access, and efficiency they experience in other walks of life. Being able to email your physician or send an image by cell phone only became a possibility several years ago, but it has rapidly gained popularity. A Harris poll in 2005 found that 80% of US adults surveyed would like to use online communication to ask their doctor questions without an office visit.13 In short, patients' expectations regarding access to health care have changed.
Dermatology patients are no exception—50% express willingness to send images to their doctor in return for faster diagnosis and treatment.14 The multibillion dollar health and wellness market suggests that significant willingness to pay may exist for an expedited, if remote, dermatological consultation service. However, only 36% of those surveyed in the Harris poll were currently willing to pay for online access to their physician. This suggests that the proponents of teledermatology have yet to convincingly demonstrate the value of this service to patients. The convergence of a supply problem, a feasible solution, and changing consumer demands has, however, created an exciting opportunity for teledermatology to show its value.
Teledermatology should not purely be defined by what has already been accomplished in this field. The future possibilities to deliver dermatological care in a manner free from geographical and temporal boundaries are extensive, and the barriers, incentives, and challenges in this field are rapidly evolving. Although rapid technological advances facilitate the development of newer and better teledermatology systems, such speed of progress can pose a challenge when attempting to validate these services. Reviews on the topic become rapidly outdated, and the technology used in many trials is often obsolete by the time results are published. For this reason, the discussion will not focus on technical requirements; instead, it will focus on areas of current expertise and probable future growth.
What is the Current Scope of the Field?
Improvements in communications technology have allowed for the transmission of information between individuals to be quite simple and efficient. When the practice of teledermatology first began, most communication was between physicians (generally specialist to generalist). However, teledermatology has since evolved to allow direct communication between dermatologists and patients.
Currently, the 2 approaches to teledermatologic communication are store-and-forward and live interactive technology. Store-and-forward teledermatology uses an asynchronous approach independent of time and place, and it allows for static images and clinical information to be transmitted either from physician to physician or patient to physician via the Internet or satellite. Live interactive teledermatology operates in real time via a videoconferencing link and is structured like a traditional in-office visit, allowing for skin examination with the use of special high-definition video cameras. Often live-interactive teledermatology visits integrate the use of static images for tracking of skin lesions, which demonstrates how these technologies can be used in conjunction with one another.
Both store-and-forward and live-interactive models of care have strengths and weaknesses, but the increased efficiency and flexibility of asynchronous communication seems likely to fuel a move towards this being the dominant approach in the future.
Management of chronic skin disease
Supporting ongoing management of existing patients with chronic skin conditions may prove to be one of the most valuable applications of these techniques. Delivering remote follow-up care to patients is an area of considerable potential. Binder et al demonstrated the role of teledermatological follow-up monitoring for patients with chronic leg ulcers.15 . After an initial outpatient visit, teledermatological follow up was performed by home-care nurses. During the study, 71% of leg ulcers improved and acceptance of this form of wound monitoring was high in patients, home-care nurses, and wound experts.
Many other chronic dermatological diseases, including acne, rosacea, and psoriasis, may be satisfactorily assessed and managed through the use of digital images. A number of trials are being conducted in this area. Their scope ranges from examining the ability of patients to self-image and forward photos to their dermatologist to assessing the value of teledermatological consultations or e-consultations in areas of the world where dermatologists are scarce and patient prioritization for face-to-face consultation is key. These approaches are designed to allow patients in the community, under the care of dermatology services, to remain connected to their provider without having to attend an office visit. This delivery model provides ongoing access to care while providing doctors with the flexibility to spend clinic time with those patients who require face-to-face management.
Patient triage
By providing a means by which to triage patients, teledermatology has the potential to deliver a solution for long wait times for patients who may need urgent dermatological care. Triage of patients suspected of having skin cancer through digital images has been shown to be effective in significantly decreasing time to diagnosis and surgical treatment when compared with the conventional referral system.16 Hsiao and Oh found that for conventional and teledermatology referrals, respectively, the mean time intervals for initial consult were 48 days and 4 days, for biopsy were 57 days and 38 days, and for surgery were 125 days and 104 days. Other studies have also demonstrated the successful use of teledermatology for the shortening of wait times for such patients.17,18,19
Triaging of outpatient dermatology referrals using teledermatology is also being examined. One study by Eminovic et al found that a quarter of dermatology referrals could be managed without a visit to a dermatologist,20 but this number varies. Studies evaluating store-and-forward teleconsulations have reported 13-58% of dermatology clinic visits were avoided or could have been avoided with the use of this system, while studies evaluating live-interactive teledermatology reported that 44.4-82% of clinic visits were avoided.21 Although both modalities of teledermatology can technically be used to triage patients, store-and-forward teledermatology has a greater potential for integration into this role, owing to its efficiency, need for less resources, and low cost.
Education and support for physicians and patients
Another valuable use of communications technology is in the provision of dermatology training and education. Educational programs may produce a significant increase in dermatology knowledge scores, demonstrating value to the recipients.22 Teledermatology can also be used to train dermatology residents. Residents in one training program used a digital camera to obtain images from all consultations. These images were then viewed and discussed with an attending dermatologist at a distant site. High levels of diagnostic accuracy were demonstrated when these images were combined with a clinical history.23
In the current US system, many patients are managed without input from a dermatologist, making it essential for dermatologists to reach out to their colleagues and ensure they have access to support and educational resources to enable the best diagnostic and management decisions to be made. Through the development of decision support tools, nondermatologists have been able to increase their diagnostic expertise in assessing nonmelanoma skin tumors.24 In addition, communications technology (eg, online forums, email) can be used to facilitate discussion and knowledge exchange between a general practitioner and a specialist to further support patient management decisions. To date, such technology has primarily been used to enable consultations involving generalists and specialists; however, subsequent applications will likely increasingly involve direct communication between dermatologists and patients.
Dermatology patients with chronic skin disease may also benefit from telecommunication tools, such as the Internet, which can provide patients with educational information and a supportive environment where they can communicate with others about the stresses associated with their chronic dermatological conditions. A 2009 study examined the role of online support communities in patients with psoriasis.25 After beginning participation in the online support communities, 41% of patients reported an improvement in their psoriasis, half reported an improvement in their quality of life, and greater than 60% reported having better availability of social support. Although further research in this area is necessary, this study illustrates the potential positive impact online communities can have in patients with chronic disease.
Teledermatology Versus Conventional Care
Demonstrating equivalence
As with the implementation of any new intervention or technique, demonstrating the equivalence of teledermatology with the current best available practice is essential. Technological interventions should not be exempt from the rigorous process of validation, but they do present particular challenges.
Ideally, interventions would be assessed through the measurement of clinical outcomes such as change in severity of disease and patient-related factors (eg, morbidity, mortality, quality of life). However, the rapid evolution of technology diminishes the utility of lengthy clinical trials to assess such patient-related clinical outcomes. As a result, trials of telemedicine interventions often opt to evaluate process measures, such as diagnostic or treatment concordance, which are important in examining the performance of teledermatology as a clinical tool.
Process measures
The following is a summary of results from studies that have evaluated teledermatology process measures. For a more detailed review, please refer to Whited, 2008.26
Diagnostic reliability
- Store-and-forward
- Complete diagnostic agreement, 41-89%
- Partial diagnostic agreement, 51-95%
- Real-time interactive
- Complete diagnostic agreement, 54-80%
- Partial diagnostic agreement, 80-99%
Diagnostic accuracy
- Store-and-forward
- Four studies found rates between teledermatology (complete accuracy, 53-71%; partial accuracy, 68-85%) and in-person assessment (complete accuracy, 59-72%; partial accuracy, 80-97%) to be similar.
- One study found accuracy rates of teledermatology (complete accuracy, 79%) higher than those of in-person assessment (complete accuracy, 30-42%). In this study, teledermatologists were able to consult with each other and request additional clinical information.27
- Real-time interactive teledermatology - No data available
Management reliability
- Agreement rates for biopsy recommendations when using store-and-forward and real-time interactive teledermatology are high overall.
- One study showed diagnostic testing recommendations (including biopsy) to be unreliable among teledermatologists, while medical management decisions were comparable to those made by clinic-based examiners.21
- Dermatologists report they feel less certain of their diagnoses when conducting a store-and-forward consultation compared with a face-to face encounter, which may explain the 10% higher biopsy recommendation rate in the teledermatology group noted in one study.28 However, this higher biopsy rate may be a necessary trade-off to ensure an equivalent standard of care.
Other process measures26
- Store-and-forward
- Helps to avoid unnecessary dermatology visits (visits avoided, 13-58%)
- Leads to decrease in time to intervention
- Leads to decrease in time to initial contact with a dermatologist
- Leads to decrease in length of consult
- Real-time interactive
- Helps to avoid unnecessary dermatology visits (avoided, 44.4-82%)
- Leads to decrease in distance traveled and travel time
- Length of consult is similar to clinic visit
Clinical outcomes
Clinical outcomes are the least researched area in teledermatology. Although the data in the preceding section demonstrate positive findings in terms of process measures, such studies cannot determine whether patients experience equivalent or improved outcomes in terms of morbidity, mortality, or quality of life. Several studies, however, have directly addressed the issue of clinical outcomes achieved via teledermatology,
A randomized controlled trial by Pak et al evaluated the clinical course of patients being consulted by store-and-forward teledermatology and conventional clinical care.29 Subjects in this study had baseline images taken and were randomized to either a teledermatology or clinic-based group. At the end of 4 months, images from subjects were taken once again and compared with those at baseline. Of subjects, 65% and 64% were rated as “improved” in the conventional care group and teledermatology group, respectively.
Another randomized controlled trial evaluated an online, asynchronous platform for the delivery of follow-up care to patients with acne. The degree of improvement in subjects managed using the online platform was equivalent to that seen in subjects who attended traditional in-patient visits (personal communication; Alice J. Watson, MRCP, MPH).
These studies are very important in that they are the first of their kind and illustrate meaningful evidence about the comparative effectiveness of teledermatology. However, more studies evaluating similar clinical outcomes must be performed before this information is accepted by physicians and patients.
Doctor and patient satisfaction
Teledermatology will only be accepted as a standard treatment modality if it is acceptable to doctors and patients. Studies assessing satisfaction rates have revealed mixed findings.
Telemedicine offers benefits to many patients, such as a shorter wait time or treatment without traveling to a remote clinic; however, patients acknowledge that a trade-off exists. A certain number of patients would still prefer a face-to-face consultation, with one study reporting that 40% felt "something was missing" when the dermatologist was not seen in person.30 Teledermatologic approaches that do not use direct patient communication raise this issue more than those that do. Generational differences may also exist amongst patients, with those in younger age groups being more comfortable with this "low-touch" approach.
Regardless of consultation modality, patients want rapid access to an accurate diagnosis and an effective treatment plan.20 They also want to be taken seriously and to receive individualized personal care.14,30,31 When these aspects of service are considered, comparably high satisfaction ratings can be achieved with either teledermatology or conventional care.
Studies assessing physician satisfaction have focused on dermatologists or referring doctors. Dermatologists are generally enthusiastic and report that they can achieve good rapport with patients using real-time technology. A majority also believed that teledermatology was just as thorough as clinic visits. Satisfaction ratings amongst referring clinicians are more variable, ranging from 21-92%.26 Low satisfaction rates tend to be associated with systems that negatively impact provider workload.30 This illustrates the importance of balancing stringent referral standards with a user-friendly system. Referring physicians must perceive a benefit to using the service in terms of increased convenience, shorter wait time, or better support. Popular systems offered referring doctors educational value and improved access to a specialist opinion.32,33
Future Applications
With the rapid evolution of communications technology leading to decreasing equipment costs, the field of teledermatology is quickly expanding. The following examples illustrate several new applications of teledermatology that leverage readily available technology, further integrate clinical tools into remote care, or expand the field of teledermatology to include interactions with other specialists.
Leveraging readily available technology - Mobile teledermatology
Mobile teledermatology refers to the evaluation of a patient’s skin condition through the use of images captured and sent by a mobile device (eg, mobile phones, personal digital assistant [PDA]). With the advancement of technology and great improvements in the quality of cameras embedded in these devices, studies have begun to focus on the role of mobile devices in areas such as remote patient monitoring, triage, medication adherence, and follow-up of patients with chronic skin disease. Mobile devices have the ability to send data and images from areas where an Internet connection is not available or is too costly. Moreover, they are a widely adopted technology, which allows for greater accessibility to teledermatologic services.
Studies evaluating diagnostic agreement between teledermatology-based images from a mobile phone camera and face-to-face dermatology have shown promising results. Braun and colleges reported a k value 0.94 for diagnostic concordance (k of 1 indicates complete concordance) between teledermatologist and face-to-face dermatologists.34 A more recent study by Ebner et al found that 71% of cases reviewed via teledermatology were fully concordant with a face-to-face dermatologist diagnosis.35 This study also found that if mobile teledermatology had been used for triage, 53% of patients could have been treated remotely.
Patients will be the primary users of mobile devices for teledermatology services, so it is crucial that they accept this technology and are willing to use it. Very little research has been performed to evaluate patient acceptability of mobile teledermatology. The study by Ebner et al, however, found that of the 58 people in their study, 60% stated they were not worried about possible uncertainty of the mobile teledermatology consultation, 69% stated they were convinced of the usability of mobile teledermatology, and 53% stated they would be willing to pay to use a similar service in the future.35 These results are promising and indicate a real interest for this technology in the dermatology patient population.
Integrating clinical tools into remote care delivery - Teledermoscopy
A dermatoscope is a noninvasive tool used by dermatologists that enables them to perform a direct microscopic examination of pigmented skin lesions (see Dermoscopy). A camera can be used to photograph the magnified images seen with a dermatoscope. These images can then be sent to others for evaluation and management recommendations. Teledermoscopy has the potential to provide images with greater detail, and thus more clinical information, to remote teledermatologists.
Although few studies have examined the reliability of teledermoscopy, results to date have been positive. A study by Piccolo et al found 91% concordance in diagnostic agreement between clinic-based dermatologists and teledermatologists.36 In 2004, results from a pilot study that evaluated melanocytic lesions using dermatoscopic and histopathologic images found a diagnostic accuracy of 83% for teledermoscopy when compared with the criterion standard.37 A 2007 study investigated the management recommendations of pigmented skin lesions after dermoscopic evaluation and found substantial agreement between clinic-based dermatologists and remote teledermatologists (k = 0.681-0.703).38
Teledermoscopy is most useful for evaluation of pigmented lesions, which most often are examined for potential malignancy. At this point, teledermoscopy is best used as a triage tool. Mobile teledermoscopy using mobile phone images for triage is being examined in Europe and, so far, has yielded promising results.39
Involving other specialists in remote care - Teledermatopathology
Teledermatopathology refers to the transmission of static images or real-time images of histopathologic sections for telediagnosis. Most studies have focused on evaluating telediagnosis with static images. These studies have been positive, with concordance rates ranging from 78-100% between telepathologic diagnosis and conventional histopathologic diagnosis.40 One study that compared real-time teledermatopathology diagnosis with diagnosis via a conventional 2-headed microscope found good agreement for teledermatopathology (k = 0.76), but better agreement for conventional dermatopathology (k = 0.93).41
In 2007, a virtual slide system (VSS) was introduced in this field. The VSS allows a whole slide to be digitized at high resolutions, which allows any part of the slide to be viewed at any available magnification. A study by Massone et al evaluated this system using biopsy specimens of patients with inflammatory skin disease and found that only 3 of 4 cases were correctly diagnosed using the VSS.42 Continued training on the VSS and ensuring availability of as much clinical data about the patient as possible will likely lead to future improvements in diagnosis with this system.
In current practice, teledermatopathology cannot replace diagnosis by conventional microscopic examination of biopsy specimens; however, it offers a possible way to try to provide a diagnosis to patients in areas of the world where dermatopathologists are not available.
Business Considerations
A service that is clinically reliable and acceptable to both patients and providers must still demonstrate its economic viability in order to be widely adopted. Here the rapid evolution of technology again poses challenges. Much of the existing work on the economic viability of teledermatology services has become redundant as a result of decreasing equipment costs. Economic analyses are further complicated by the many hidden costs, such as the opportunity cost of a patient's time, and hidden benefits, such as the intangible benefit of an earlier correct diagnosis, that are harder to quantify.
Real-time interactive teledermatology has traditionally been found to be more costly than standard care because of the need for 2 providers and complex videoconferencing equipment. However, a 2006 analysis of the real-time interactive clinic run by Partners Telemedicine to Nantucket Island showed cost savings, related in part to the lower cost of renting hospital space in a rural setting.43 Another study reduced the costs of real-time interactive equipment by using multimedia phones to perform conferencing.44
Store-and-forward technology avoids the high provider and equipment costs of a real-time interactive service, while still being less time consuming for patients. More work, however, is required to decide whether it is truly cost-effective. A study from the United Kingdom found that 45% of patients could not be adequately managed by teledermatology alone.45 Identifying the most appropriate patients to enter into this type of service may help to demonstrate its true economic value. With the integration of technology into follow-up care, significant cost savings may become apparent. Irrespective of how teledermatology evolves, thorough economic analysis remains essential before payers will embrace this new mode of care.
Lastly, new models of teledermatology allow for greater provider versatility, flexibility, and opportunities to generate revenue. Teledermatology allows for providers to have a wider geographical reach with regard to their patient population, and it enables them to offer a specialized service, which makes them a valuable commodity. Asynchronous models also offer providers flexibility regarding when they work, because teledermatology visits are efficient and can be performed at a time of convenience. The adoption of teledermatology to manage simple follow-up visits also offers an opportunity for increasing a provider’s revenue by freeing up clinic time to perform more lucrative procedures.
Adoption Challenges
A number of different areas have obstacles that limit the more widespread introduction of telemedicine services (see Media File 1).
Adoption challenges to the introduction of telemedicine services.
Although patients are becoming increasingly comfortable using technology to access health care information, telemedicine should be viewed as an adjunct, rather than a replacement, to conventional care. Any service should be tailored to meet patient needs and expectations to promote a positive interaction. Many doctors are also unsure of this new care-delivery model. A solid evidence base and a thoughtful implementation strategy are required to ensure doctors are motivated to participate in telemedicine initiatives.
As previously mentioned, the rate of technological development and increased affordability have made the tools of telemedicine more widely available. Many companies have seized on this business opportunity, offering a plethora of devices and services. Interoperability between these technologies is required to allow the development of an integrated information technology network. Consumer-grade technology is of such a standard that patients can now provide their own images and clinical information via the Internet. This introduces new concerns over issues of security and confidentiality. Secure online health care communication services are now available to link patients, doctors, payers, and pharmacies and enable clinically structured and auditable interactions to take place, including online consultations, prescription requests, appointment reminders, and delivery of laboratory results.
The Health Information Portability and Accountability Act in the United States has set standards that all initiatives must meet to ensure the protection of personal health information.46 The Joint Commission on accreditation of healthcare organizations also requires quality and safety assurances in order to provide accreditation for organizations.47 Providers are advised to liaise with their institution's privacy officer for advice on how best to achieve these required standards.
Teledermatology allows consultations to occur across state and national boundaries. This raises issues regarding licensure that must be addressed to ensure doctors are practicing within an appropriate sphere. Although no telemedicine malpractice cases have been filed to date, clarifying how responsibility for decision making is shared between referring doctors and specialists is essential. Individuals making initial steps in this field are advised to contact their malpractice carrier and inform them of their interest in telemedicine.
Reimbursement for services is an important issue in the United States. In this new field, defining what constitutes a consultation and determining at what level should ongoing care using telemedicine be reimbursed are important. Currently, reimbursement is almost exclusively available for real-time interactive services for designated nonmetropolitan areas throughout the United States, with store-and-forward system funding only provided on a very limited basis. Medicaid is funding the latter on a trial basis in Alaska and Hawaii, both of which are areas where access to specialist care is a major issue. Interestingly, some progressive international insurance companies have begun endorsing the use of store-and-forward teledermatology between referring physicians abroad and dermatologists in the Partners health care system in Boston.48
In addressing this and other barriers, the importance of standards and guidelines for practitioners becomes apparent. The American Academy of Dermatology has released a position statement on telemedicine, which offers guidelines on technology requirements, confidentiality standards, and licensing.49 Government-funded, pay-for-performance models are currently being studied in the management of chronic diseases, such as diabetes and hypertension. Markers of quality care, such as blood pressure or lipid levels, do not have ready equivalents in the management of skin disease. This would make the implementation of a similar model in dermatology a more controversial proposition.
Conclusion
Changing consumer demands, the limited supply of dermatologists, and technological advances are driving interest in teledermatology. Consumers are increasingly keen to obtain rapid access to specialist advice and are seeking the convenience in health care that they enjoy in other service industries. Dermatologists are in short supply and are geographically maldistributed, creating a lack of access to care for patients in many parts of the country.
For widespread, sustainable adoption of teledermatology initiatives to occur, efficacy, acceptability, and economic viability must all be demonstrated. Different populations vary in their requirements, and customized, integrated solutions are necessary to engage interest and maintain usage. This flexibility must be coupled with guidelines for practice that ensure a high standard of care for all recipients, especially as the international community becomes increasingly involved. A number of steps are required to ensure that regulatory standards are met, and, although these may seem daunting to newcomers to the field, this mode of practice is steadily moving towards the mainstream.
Teledermatology has enormous scope as an adjunct to current practice in all settings and provides a means of access to care for many patients currently denied specialist attention. Much work remains in order to create a solid research base that demonstrates the value of this service for providers and patients. Providing a safe, equitable service that delivers health outcomes comparable to conventional care is the ultimate aim.
Multimedia
 | Media file 1: Adoption challenges to the introduction of telemedicine services. |
Keywords
teledermatology, telemedicine, Internet dermatology, online dermatology, web-based dermatology, web-based diagnosis, Internet diagnosis, teleconference diagnosis, telehealth, tele-health, tele-medicine, tele-dermatology, store and foreword teledermatology, live-interactive teledermatology, e-health, pay-for-performance model, pay for performance model
The authors and editors of eMedicine gratefully acknowledge the contributions of previous Chief Editor, William D. James, MD, to the development and writing of this article.
More on Teledermatology |
| References |
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Further Reading
Keywords
teledermatology, telemedicine, Internet dermatology, online dermatology, web-based dermatology, web-based diagnosis, Internet diagnosis, teleconference diagnosis, telehealth, tele-health, tele-medicine, tele-dermatology, store and foreword teledermatology, live-interactive teledermatology, e-health, pay-for-performance model, pay for performance model
