Teledermatology in Australian public hospital emergency departments: A review

Abstract

Dermatological complaints account for around one in ten emergency department (ED) presentations.¹ In Australia, teledermatology in the ED is one strategy to increase access to dermatologic advice, especially in rural and remote communities where barriers such as travel time or lack of dermatology on-call cover, prevent timely communication and dermatological care.²

Diagnostic accuracy with in-person dermatology for asynchronous store-and-forward (SAF) teledermatology and real-time (RT) videoconferencing systems is 71–98%, while mobile phones as a platform for hybrid teledermatology reveal potential value in the early diagnosis of skin cancer.^{3, 4}

However, there is currently limited teledermatology implemented in the emergency department, despite having already been successfully trialled.^{5, 6} We reviewed the literature to identify the current benefits and limitations of teledermatology use in the hospital ED and highlight how this technology is best considered complementary to in-person dermatology.

Our literature search returned four eligible studies (n = 660 patients) which were all based in the Australian healthcare system (Table 1).

The most common diagnoses were dermatitis/eczema, infection, and drug eruption (Table 2). Three of four studies conducted store-and-forward technology^{2, 3, 7} while one study analysed RT teledermatology.⁵ The response rate within 3 h for dermatology advice ranged from 56% to 94%.³ The benefits and limitations of teledermatology in the ED have been summarised below.^{2, 3, 5, 7}

This review reveals the value of ED teledermatology, with 50% of referrals being converted to non-urgent outpatient review, reducing the need for costly hospital admissions.³ In France, an RT teledermatology study of four ED's (n = 111) revealed that ED physicians recommended admission more frequently (8.2% vs. 7.2%, p < 0.001), while dermatologists chose to discharge patients more often (46.8% vs. 39.1%, p < 0.001).⁶

Muir and colleagues³ reported up to 98% diagnostic concordance using SAF technology in ED. Furthermore, the management concordance between the teledermatologists and in-person dermatologists were complete agreement in 96% of cases (n = 48).

More than 80% of images in this review were sent with adequate resolution. Computer workstations on wheels (WOW) are mobile nodes of a hospital's electronic medical record and with high-definition cameras, WOW's could be a solution to managing dermatological conditions in contexts where specialists are scarce.

While many SAF studies used an internal teledermatology email to receive teledermatology consults, referring clinicians sometimes sent correspondence through personal email accounts.^{2, 7} Some medico-legal concerns preventing dermatologists implementing teledermatology include patient confidentiality and consent for the capture, storage, transfer and subsequent use of images. Instant messaging platforms such as WhatsApp are currently used as a form of SAF teledermatology.⁸ An important consideration is ensuring clinical information is quickly and easily importable to the patient file for contemporaneous documentation, and deleted off personal devices.⁹ The software to do this already exists (e.g., Camera Capture in PowerChart) but licencing can be expensive and hospitals must be willing to invest in software licences and increased data storage to accommodate images.⁹

In addition to WOW's, smartphone devices with purpose-built apps (e.g., Microsoft Teams' MedSync) that integrate with electronic medical records offer confidential image capture and storage. However, employees require app education, and there needs to be a critical mass of users so there is no delay waiting for others to download the app.⁹

In Biscak and colleagues'⁷ study, 100% of clinician respondents indicated that teledermatology was useful for learning and training purposes. However, times when teledermatology was less efficient included poor image quality delaying diagnosis, or patients receiving incorrect diagnoses requiring further consultation.⁴

For patients, the preference for teledermatology over usual care ranged from 38 to 86%, with factors such as longer waitlists for an appointment and the long distance to travel supporting this technology.⁴

Only 44% of all teledermatology referrals were from ED doctors across the four studies. All study participants were of a non-consecutive convenience sample of patients, thus are subject to selection and misclassification bias.

There is also no literature on the use of WOW's in the ED for teledermatology consultation and have mainly been studied in the context of telestroke.

Furthermore, there is a lack of follow-up studies measuring patient outcomes following the implementation of management plans. Without longitudinal data, there is a risk that inadequate patient response or adverse outcomes are missed.

Teledermatology enables patients to receive a diagnosis and treatment plan while waiting in the ED, which is an efficient solution to provide specialist dermatology care to communities afflicted by limited resources, or a pandemic. Teledermatology can reduce resultant admissions in evaluating dermatological conditions with great accuracy, minimise travel times, and improve dermatology access, to optimise patient outcomes.

None.

None declared. This work has not previously been published.

Not applicable.