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Interactive Teledermatology
Updated: Nov 17, 2009
Dermatology Teleconsultations Using Interactive Video Technology
Teledermatology is the delivery of health care using long-distance communication technology. This can be via a simple phone conversation or a more complex exchange of both sound and images. The latter constitutes interactive video teleconsultation. To understand video consultations better, is must be appreciated that they depend not only on interactive video but also on still-image transmission, which more traditionally is termed store-and-forward technology. Unlike still-image transmission, interactive video allows the examining physician to interact with both the patient and the presenter at the far end. This allows the physician to establish a better rapport with the patient, ask further historical questions, and request certain images of the patient from the presenter.
Equipment
The backbone of an interactive video consultation is a unit that captures the image and sound, compresses it, and sends it through a communication line to the person at the receiving end. A wide range of technology is available, from larger roll-about units to desktop cameras connected to personal computers. The equipment used depends largely on budget, communication lines, and the needs of the consultant.
The camera connected to the codec (a multimedia compressor/decompressor) usually offers zoom capability that provides a wide range of viewing. These cameras typically use either a single chip that shares the red, green, and blue assignment or a 3-chip camera with a dedicated chip for each of the red, green, and blue hues. A 3-chip camera provides greater color and image representation and has been shown to offer a clinical advantage in dermatologic examinations.1
Peripheral cameras are helpful in better imaging a lesion or capturing the fine detail of an eruption (see Media File 1). Peripheral cameras are available commercially and offer features that can provide varying images of the skin. The close-up image allows better classification of the primary lesion by visualizing the fine details of the lesion. Peripheral cameras typically are handheld devices. They may be mounted on a stylus that rests against the skin. This provides a consistent image and decreases movement artifact created by the presenter. Handheld devices usually operate on a fraction of a chip (ie, *chip). Similarly, they may have zoom capability that provides closer imaging. Higher-end cameras may have polarizing lenses that reduce surface reflection from the stratum corneum. This provides a deeper image in the skin below the stratum corneum. Many handheld close-up cameras have their own light source, which improves consistency among examinations.
A handheld camera provides a close-up image of a cutaneous lesion or eruption. Many off-the-shelf cameras have standardized lighting and an ability to polarize reflected light.
Often, cameras or software packages sold with the unit have freeze-frame capability, which is critical for transmitting a stationary image for adequate inspection. This aspect of interactive video teleconsultation is similar to store-and-forward teleconsultation.
Monitors are critical in viewing the broadcast image. The choice of monitor may be determined largely by the system used. A personal computer system likely uses a standard computer monitor. Larger roll-about systems use more standard television monitors. The author is not aware of any studies that specifically address different monitors for teleconsultations, but personal experience suggests that bigger is not necessarily better. One resolution (600 X 800 pixels) on a smaller monitor may offer a better image than the same density on a larger screen.
Other peripheral devices may prove useful to the teledermatologist. Document cameras may allow physician examination of outside laboratory or pathology reports. These also may provide a good-quality image of limited and accessible areas, such as the hand. Some teledermatology programs have microscope attachments that allow real-time evaluation of potassium hydroxide or scabies preparations. Dermatopathology slides also may be reviewed using such equipment. Also see Digital Photography.
Telecommunications Choices
The method of sending data may depend on the local telecommunication service, cost, and desired frame speed. Frame speed is the number of frames per second and is important in determining the fluidity of the perceived motion. Frame speeds at or above 30 frames per second are perceived as more fluid, while frame speeds less than 30 frames per second may become choppy.
The most easily accessible telecommunications line is a standard telephone line or POTS (plain old telephone service). This level of service is available in most regions, but because of limited bandwidth (64 kbps), it only can achieve slower frame speeds. Available off-the-shelf technology for video conferencing may have a limit of 8 frames per second or less, providing a disjointed or choppy video image. Digital images sent via cellular phones, with audio interaction, have been a useful adjunct to managing chronic ulcers in a small number of patients.2
Integrated services digital network lines have a wider bandwidth (128 kbps) and allow a faster frame speed but are more costly and not accessible as easily, especially in the rural communities where a larger volume of health care may be delivered using telemedicine.
The Internet, while not a specific form of telecommunications technology, offers a more easily accessible conduit for dermatology teleconsultations. Slow frame speed limits the effectiveness of interactive video teleconsultations. This may be less of a concern as the second generation of Internet technology develops. Security and, thus, confidentiality may be more difficult to assure with more widely used telecommunication lines such as the Internet and POTS.
T1 lines have broader bandwidths (1,544 kbps) but, again, are less available and more costly than other more traditional telecommunications technology. T3 (45,000 kbps), microwave, and fiberoptic technologies also are not accessible easily and are costly. Satellite technology offers accessibility, but cost and equipment requirements limit use.
Conducting a Teleconsultation
Consultations using interactive video require the dermatologist to be at one end and the patient and presenter at the other end in real time. The consultant should be located in a quiet area that provides privacy (see Media File 2). The presenter may be another physician, a physician assistant, or a nurse trained in using the equipment. The presenter and patient are in a modified examination room that contains all necessary equipment. In addition, ancillary technical personnel may be in attendance to help with the equipment. Patients should be made aware that technical personnel may observe the consultation. Some facilities use consent forms to inform patients in writing of the presence of nonmedical personnel.
Telemedicine consultation rooms at the Brody School of Medicine at East Carolina University allow physicians privacy in interacting with the patient and presenter. Each room has a workstation with ample desk space on which physicians can to complete their written consultations.
Unlike a live clinical setting in which the physician walks into the patient's room, the patient may be brought into the telemedical examining room where the physician already is seated and on screen. The patient is brought into the examining room in a gown or appropriate attire. If the patient needs to disrobe, the camera should be turned off or directed away from the patient to provide privacy.
The advantage of video teleconsultations is that their interactive nature allows the physician to establish a rapport with the patient. The consultation begins with greetings and introductions. These usually are instigated by the examining physician but may be initiated by the presenter.
The nature of the technology necessitates that the consultant begin by taking a history. While this may appear to be natural for most physicians, it is contrary to the more common dermatologic practice of examining the patient first and then taking a history to support or refute the working diagnosis. The dermatologist loses the ability to scan effectively while talking to the patient, which results in an overall inefficiency of the examiner's time, as noted by researchers.
After the introductory history is taken and general observations are made using the main camera, the dermatologic consultant may instruct the presenter to show a particular lesion or portion of the rash using a peripheral camera. This may be directed by the physician or by the presenter, if an area of concern or an area representative of cutaneous involvement has been noted. The dermatologic consultant must have an idea of the clinical capabilities of the presenter. Often, the consultant asks the presenter to feel an area of concern to assess its thickness and consistency, whether fluctuance is present, or to confirm the presence of a characteristic of a rash or lesion. Confidence in the presenter may be gained as a function of time and repeated practice, or it may involve direct training of the presenter in a live patient setting by the consultant.
Observations, diagnoses, and treatment options are discussed with the patient. Diagnoses and treatment recommendations are forwarded to the physician requesting the consultation or may be sent directly to the pharmacy. Instructions for medication use can be reviewed with the patient. Plans for follow-up care, (1) in the referring physician's office, (2) with the telemedicine clinic, or (3) live with the consulting dermatologist, are discussed.
Etiquette
Telemedicine can be a strange environment for both the patient and the physician new to the technology (see Media File 3). The practicing teledermatologist should become familiar with the equipment to be more at ease with it and to provide better service. If the teledermatologist is not comfortable, it is likely that the patient also will be uncomfortable with the technology.
Telemedicine examination rooms at outlying clinics are modified clinical rooms. The viewing monitor and camera are placed in front of the table for a more standard interaction. Presentation tools, such as handheld dermatology cameras, are beside the examination table.
An acceptable on-screen view of the physician should be presented to the patient. A head-and-shoulders shot usually is the best. Some physicians not familiar or comfortable with the technology present an image of a small talking head in the lower right-hand corner of the monitor. Conversely, too close an image, with the face taking up the entire screen, presents an unrealistic image of the physician.
Most patients seem to be comfortable with the technology, but attention should be paid to the concerns of the patient. If hesitation by the patient is perceived, taking a few minutes to talk about the technology can make the patient more comfortable. Inquiring if the patient has ever been on television before usually can elicit a smile and open a dialogue.
Physicians should maintain and respect the patient-physician relationship at all times. Patient awareness of ancillary personnel can be important. Interactive video conferencing units have mute buttons that should be used at the discretion of both the physician and the presenter to minimize overheard stray comments not meant to be a part of the physician-patient interaction.
The presence of 2 physicians (one at each end of the transmission) occasionally can result in difficulty in determining who is directing interaction with the patient. Often, the presenting physician may want to direct the consulting physician to certain aspects of the history or physical examination that the consultant believes are not relevant. This may put the consulting physician in the position of having to correct or challenge the on-site physician. If the consultant chooses not to redirect the presenting physician, this may result in an overall inefficiency of the consult. The same may happen with nurses and physician assistants. Although this is difficult to work out ahead of time, the consultant dermatologist should be aware that this difficulty may exist in certain circumstances.
Accurate information must be conveyed to the dermatologist. Tumors of the skin can be deceptively large on a 36-inch television monitor. The presenter always should have an appropriate device for measuring tumors. The exact size and location should be confirmed for the consultant and appropriately recorded in the patient's consultation note.
Suitable Cases
No formal study has addressed which cases may be suited better for video teleconsultation. In the author's opinion, most skin diseases can be addressed appropriately via teleconsultation. Some situations exist in which it may be inappropriate to use the technology.
Potentially life-threatening dermatoses, such as toxic epidermal necrolysis, are not good candidates for teleconsultation. The time required to arrange an emergent teleconsultation is spent better in transporting the patient to an appropriate facility for definitive diagnosis and management.
Concern has been expressed regarding evaluation of pigmented lesions using interactive video teleconsultations. The ability to diagnose melanoma via telemedicine has not been studied well. A case report exists of a melanoma diagnosis using interactive video conferencing in which the teleconsultation did allow confirmation of the diagnosis and facilitated more timely management of the tumor.3 The capability to image pigmented lesions with both standard and polarized lighting can result in an accurate analysis of a pigmented neoplasm. Teledermoscopy can also facilitate the evaluation and management of pigmented lesions via telemedicine.
Whether the use of interactive video consultation can delay an appropriate biopsy has not been studied and may depend to a large degree on geography and accessibility to a specialist, factors that also affect nontelemedicine referrals. It would be naïve to believe that a melanoma never will be missed by teleconsultation because that would mean that teleconsultation has a better track record than live clinical dermatology. If the evaluation of melanoma by telemedicine is excluded, the evaluation by dermatologists of all benign pigmented lesions to rule out a melanoma also is excluded.
Certain body locations are difficult to image; therefore, they are poor candidates for interactive video teleconsultations. Currently, cameras for dermatologic use do not provide adequate imaging of lesions on mucosal surfaces. Lesions deep in the oropharynx or vaginal mucosa may not be visualized well. A lesion or rash in the scalp may be difficult to see because hair blocks the view. Some patients may feel uncomfortable allowing images of rashes or lesions involving the genitalia, perirectal area, or female breasts to be viewed via teleconsultation. This should be discussed with the patient prior to referral for teleconsultation.
In particular, evaluation of a child can be difficult. Small children are unable to hold still for the camera. In this author's experience, an adequate image usually can be obtained to establish a working diagnosis and treatment plan. What is important, as in any teleconsultation, is that the examiners suggest a live examination if they feel they are not getting adequate images using telemedicine. Certainly, individual cases may exist in which telemedicine is ineffective.
Perhaps the most inappropriate examination for telemedicine is a total-body screening for abnormal moles or skin cancer. The lack of ability to scan a patient's skin or the sheer number of an individual's moles can make telemedicine either an ineffective or inefficient form of health care delivery. In this author's experience, interactive teleconsultation is most effective when an opinion is solicited regarding a specific lesion or rash.
Studies have shown interactive teledermatology has comparable efficacy to in-person examination and often is deemed more effective than store-and-forward consultations.4,5,6
Legal Issues
Legal issues touch all aspects of medicine and no less so in telemedicine. The technology is moving beyond existing law in many medicolegal areas of telemedicine. The 2 primary areas of focus in the legal arena are licensure and liability.7,8
Licensure in the United States has always been at the discretion of the individual state medical licensing board. With the exception of communities that may border on another state, physicians need to be licensed to practice in the states in which they see patients. This requirement has limited the locations in which physicians may see patients for most interactive video consultations. This may not be an issue for many programs built around a specific T1 framework, because their spoke sites are in a limited section of the state. Some radiology programs have served multiple states; it is incumbent on the physicians to become licensed in each of those states.
As lower-end video consultation capabilities develop using POTS or Internet access, it will become easier for clinicians to seek consultations across state lines. Licensure will become a bigger concern. Some states have a special designation for telemedicine consultation, but as yet, this is not universal. Interest exists in the telemedicine community in establishing national licensure that would allow physicians to practice in any state, but currently, this is not available.
Tort or case law determines liability issues. Anticipating legal issues is difficult. A specific precedent does not exist until a case is brought before the court and a ruling is made regarding that issue. To date, little litigation exists regarding telemedicine; many issues of liability remain conjectural.
Issues of whether a duty to the patient has been established are critical in determining liability. Certainly, the parameters of interactive video, in which a specific patient with a specific condition is addressed by a specific physician, suggest that a duty to the patient has been formed. The liability issue may be confounded more by product liability. For example, did a problem with the technology (hardware or software) hamper the consulting physician's ability to form a reasonable opinion and result in subsequent harm to the patient? This will remain an area of speculation until specific cases are brought before the courts.
Practicing teledermatologists must be aware of the liability issue of malpractice coverage. Many malpractice carriers insure the physician for medical practice only in a specified geographic location. If their practice of telemedicine carries them beyond that geographic confine, they may find they are practicing medicine without malpractice coverage.
Conclusion
Interactive video teleconsultations in dermatology are becoming somewhat of a dinosaur, since more programs are moving towards store-and-forward technology as an effective cost-saving means of tele–health care delivery. Evidence is still lacking regarding the efficacy of interactive video telemedicine because the small sample sizes in the studies conducted preclude any strong affirmation of the technology.
Store-and-forward technology is more efficient because the consultation becomes independent not only of distance but of time. Cost is an issue in interactive video teleconsultations; however, similar to any technology, the cost decreases with time. Quality also increases, and as the lines of cost and quality cross, opportunities will improve for using interactive teleconferencing for appropriate dermatologic consultations. Interactive video consultation provides an opportunity to interact with the patient that store-and-forward technology does not. Interactive video allows the physician to fill in gaps in the history, to view different angles of the same lesion, and to know the patient. This last aspect is the greatest strength of interactive video in delivering health care.
Multimedia
 | Media file 1: A handheld camera provides a close-up image of a cutaneous lesion or eruption. Many off-the-shelf cameras have standardized lighting and an ability to polarize reflected light. |
 | Media file 2: Telemedicine consultation rooms at the Brody School of Medicine at East Carolina University allow physicians privacy in interacting with the patient and presenter. Each room has a workstation with ample desk space on which physicians can to complete their written consultations. |
 | Media file 3: Telemedicine examination rooms at outlying clinics are modified clinical rooms. The viewing monitor and camera are placed in front of the table for a more standard interaction. Presentation tools, such as handheld dermatology cameras, are beside the examination table. |
Keywords
interactive teledermatology, interactive video teleconsultations, IAVT, interactive video conferencing, IVC
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.
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References
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Further Reading
Keywords
interactive teledermatology, interactive video teleconsultations, IAVT, interactive video conferencing, IVC
