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Original Investigation |

Emergency Department Diagnosis and Management of Skin Diseases With Real-Time Teledermatologic Expertise

Tu Anh Duong, MD, MSc1,2; Florence Cordoliani, MD3; Caroline Julliard, MD, MSc3; Emmanuelle Bourrat, MD3; Stephanie Regnier, MD, MSc3; Loïc de Pontual, MD4; Christophe Leroy, MD5; Sébastien Gallula, MD6; Caroline Aparicio, MD6; Nicolas Legendre, MD7; Martine Bagot, MD, PhD3; Fabien Guibal, MD, MSc, MBA3
[+] Author Affiliations
1Department of Dermatology, Hôpital Henri Mondor, AP-HP, Créteil, France
2Department of Design Engineering, Ecole Centrale Paris, Chatenay-Malabry, France
3Department of Dermatology, Hôpital Saint Louis-Lariboisière, AP-HP, Paris, France
4Emergency Department, Hôpital Jean Verdier, Bondy, France
5Emergency Department, Hôpital Louis Mourier, AP-HP, Colombes, France
6Emergency Department, Hôpital Saint Louis-Lariboisière, AP-HP, Paris, France
7Emergency Department, Hôpital Saint Antoine, AP-HP, Paris, France
JAMA Dermatol. 2014;150(7):743-747. doi:10.1001/jamadermatol.2013.7792.
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Importance  Skin conditions are a common reason for patients to consult emergency department (ED) physicians.

Objective  To evaluate real-time teledermatologic expertise with the use of mobile telephones for the diagnosis and management of skin conditions in patients seen in the ED.

Design, Setting, and Participants  This observational study of adults who consecutively consulted in the ED for a dermatologic condition was conducted under routine conditions in the ED from May 1, 2008, through June 30, 2010.

Main Outcomes and Measures  Diagnosis agreement and management concordance.

Results  One hundred eleven patients were enrolled in the study. Eighty-three patients (74.8%) were evaluated using videoconferencing. Dermatologic remote expertise invalidated, enlarged, or clarified ED physicians’ diagnosis and management in 75 of 110 cases (68.2%). Videoconferencing improved the diagnostic performance in 57 of 83 cases (68.7%) (P < 10−4). Management concordance was moderate between ED physicians and dermatologists for specialist consultation within 24 hours (κ, 0.49; 95% CI, 0.14-0.84) and immediate hospitalization (κ, 0.49; 95% CI, 0.41-0.57). Patients were significantly more often discharged by dermatologists (46.8% vs 39.1%) (P < 10−4).

Conclusions and Relevance  Compared with standard hardware, new-generation mobile devices reduce the cost of videoconferencing, increase the versatility of teledermatology, and decrease general practitioner investment time.

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Study Protocol in 3 Steps

Step 1: diagnosis and management using still images; step 2: diagnosis and management using videoconferencing; and step 3: experts’ diagnosis or management comparison using still images or videoconferencing. ED indicates emergency department.

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Comment: Emergency Department Diagnosis and Management of Skin Diseases With Real-Time Teledermatologic Expertise
Posted on May 25, 2014
Monika Janda (1), Anna Finnane (2), H Peter Soyer (2).
(1) School of Public Health, Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia (2) Dermatology Research Centre, The University of Queensland, Scho
Conflict of Interest: HP Soyer is a shareholder of E-derm Consult GmbH and MoleMap by Dermatologists Ltd.
We read with interest the article Emergency Department Diagnosis and Management of Skin Diseases With Real-Time Teledermatologic Expertise by Duong et al. (1) who found that dermatology remote consultation confirmed 31% of the diagnosis, and changed, enlarged or clarified the dermatological diagnosis by emergency department physicians in 35%, 14%, and 18% of cases, respectively. They found that videoconferencing rather than discussing a still image improved the diagnostic performance in 57 of 83 cases (however only 83 of the 111 consultations also proceeded to videoconferencing). Videoconferencing may be beneficial, but is often not feasible as it lengthens the time of consultations, and has many technological challenges, both when used to aid communication between two doctors (2), or patients and doctors (3). Similar in the present study, unreachable network, poor image quality, and patients’ impatience were reasons for 25% of patients not continuing with the videoconferencing. Store and forward methods are much more likely to succeed, but need optimal picture quality and sufficient information about the condition history to be accurate (4). Could Duong et al comment on the picture quality in their study? We recently conducted an audit of 167 store and forward teledermatological consultations to emergency departments in Queensland, Australia, during the year of 2012 (5). The main referring condition was rash (65%), followed by skin lesions (13%), and we were able to provide a telediagnosis for 56% of cases within 3 hours. Our teledermatological diagnosis consisted of dermatitis/eczema, infection and drug eruption in 23%, 20%, and 17% of cases, respectively. Most of the doctors requesting a teledermatology were recent graduates, 85% were seeking assistance with obtaining, 35% confirmation of diagnosis. Duong et al. estimate that teledermatologists consultation saved some patients from hospital admission, and cost savings which could contribute to funding teleconsultations. Adequate compensation for consultant teledermatologists is a major issue holding back teledermatology (6). In Australia, current Medicare reimbursement items reimburse real-time videoconferencing, a proposal for store and forward dermatology is pending (7). Store and forward teledermatology could be particularly beneficial for rural and remote patients, who currently do not have access to specialist dermatology services to the same degree as urban residents (3).References1. Duong TA, Cordoliani F, Julliard C, et al. Emergency Department Diagnosis and Management of Skin Diseases With Real-Time Teledermatologic Expertise. JAMA Dermatol. 2014.2. Chao JT 2nd, Loescher LJ, Soyer HP, Curiel-Lewandrowski C. Barriers to mobile teledermoscopy in primary care. J Am Acad Dermatol. 2013;69(5):821-824.3. Consumers Health Forum of Australia. Our Health, Our Community 2014. http://ourhealth.org.au/ Accessed May 20, 2014.4. Janda M, Loescher LJ, Banan P, Horsham C, Soyer HP. Lesion Selection by Melanoma High-Risk Consumers During Skin Self-examination Using Mobile Teledermoscopy. JAMA Dermatol. 2014.5. Biscak TM, Biscak TM, Eley R, Manoharan S, Sinnott M, Soyer HP. Audit of a state-wide store and forward teledermatology service in Australia. J Telemed Telecare. 2013;19(7):362-366.6. Lozzi, G.P, Soyer HP, Massone C, et al. The additive value of second opinion teleconsulting in the management of patients with challenging inflammatory, neoplastic skin diseases: a best practice model in dermatology? J Eur Acad Dermatol Venereol. 2007;21(1):30-34.7. Australian Government, Department of Health. Consultation Protocol to guide the assessment of asynchronous specialist dermatology services delivered by telecommunications. 2014. http://www.msac.gov.au/internet/msac/publishing.nsf/Content/1360. Accessed May 20, 2014.
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