GLOBAL TELEDERMATOLOGY: A SPECIFIC WEB APPLICATION FOR DERMATOLOGICAL CONSULTATION

Massone C,¹ Hofmann-Wellenhof R,¹ Gabler G,² Dong H,³ Kaddu S,¹ Di Stefani A,^1,4 Zalaudek I,¹ Argenziano G,⁵ Soyer HP¹

Department of Dermatology, Medical University of Graz, Graz (Austria) ¹
Department of IT and Telecommunications, Graz University Clinics & General Hospital, Graz (Austria) ² 
Department of Dermatology, University of Zhengzhou, Zhengzhou (P.R. China)³
Department of Dermatology, University of Rome Tor Vergata, Rome (Italy) ⁴
Department of Dermatology, Second University of Naples, Naples (Italy)⁵


Corresponding author:
H. Peter Soyer, MD
Department of Dermatology
Medical University of Graz
Auenbruggerplatz 8, A-8036; Graz (Austria)
Phone: 0043-316-385-3365
Fax: 0043-316-385-4957
E-Mail: peter.soyer@meduni-graz.at  


Abstract 
Telemedicine is a new tool in medicine that utilizes modern telecommunication technology to exchange expert medical information between two or more distant medical centers. The inherently visual nature of dermatology makes it easily applicable to virtual medicine and store-and-forward systems have proven to be highly reliable and accurate in teledermatologic diagnosis compared to traditional face-to-face diagnosis. telederm.org is a user-friendly application launched in May 2002 whereby dermatologists, general practitioners or any healthcare workers interested in teledermatology can quickly and easily seek from a pool of expert consultant diagnostic advice regarding interesting and unusual cases in clinical dermatology, dermatopathology and dermoscopy. As of November, 2003, more than 250 healthcare professionals, coming from 40 different countries, subscribed to the services offered by telederm.org. Over the first 18 months since inception, telederm.org has answered 593 requests for consultations. The goal of telederm.org is to develop a best-practice model for teleconsultation using skin diseases as a paradigm. A given skin condition can be diagnosed virtually by many different experts in dermatology, thereby stimulating exchange of knowledge and expertise. By providing an interactive discussion between physicians at the point of care and experts from many different countries, telederm.org seeks to raise the level of competence of physicians and dermatologists on a worldwide level. 

Keywords: teledermatology, telemedicine, e-visits, internet, dermatology, dermatopathology, dermoscopy

Internet Health 2004;3(1):e3

Introduction
Telemedicine is a new tool in medicine that utilizes modern telecommunication technology to exchange expert medical information between two or more distant medical centers.[1] Telemedicine is particularly useful in supporting medical care in centers with few experts by connecting them to other centers with a high concentration of experts.[2] The specialties involved include mainly general medicine, radiology, pathology, cardiology, neurology, psychiatry, various surgical specialties (e.g., orthopedics, otolaryngology, gynecology), and medical dermatology.[3,4,5,6,7,8] 

The inherently visual nature of dermatology makes it easily applicable to virtual medicine. Technical systems previously employed include real-time videoconferences and store-and-forward systems, among others. Both real-time videoconferences and store-and-forward systems have proven to be highly reliable and accurate in teledermatologic diagnosis compared to traditional face-to-face diagnosis.[9] In particular, decisions and recommendations made by remote teledermatologists can be reliable and valid and thus have the potential to minimize personal visits of patients.[10] In some settings teledermatology can be more cost-effective than traditional dermatology, irrespective of the teledermatology system used. Patients can benefit from telemedicine by saving time and by experiencing fewer travel inconveniences. Local physicians benefit from the mentoring and educational aspects of the consultations, as well as from access to improved research facilities, and the professional interactions and opportunities to review occasional rare or unusual dermatological cases benefit the consulting experts.[11]

Telemedicine can be an invaluable means to support and improve existing medical services in developing countries. Teledermatology offers new research possibilities for a variety of dermatologic conditions and can provide a well-defined channel for interactions with experts in the field of dermatology.[12]

The telederm.org project

The telederm.org project was conceived in 2002 in the Department of Dermatology of the University of Graz by H. P. Soyer and colleagues. The basic aim of the project is to create a user-friendly application to present and discuss particular dermatological cases, with an emphasis on diagnostic procedures, diagnosis and therapy. Long-term goals include development of a research database, standardization of teledermatology procedures, and development of consensus guidelines for teledermatology. Specific activities include:

• Creation of a standardized database of comparable, compatible clinical data in the fields of clinical dermatology and dermatopathology. The images accompanying the clinical data will all be stored in the same jpg format and compression.
• Development of programs to encourage exchange of information among health-care professionals, including sharing information about disease prevention, early detection of disease, and the most effective practices in disease management
• Optimization of the software design in regard to IT-security aspects, legal aspects, sociological aspects and economic aspects
• Evaluation of intercultural aspects of virtual services to promote patient acceptance.

telederm.org was launched in May 2002. As of November, 2003, more than 250 healthcare professionals, coming from 40 different countries, subscribe to the services offered by telederm.org. Over the first 18 months since inception, telederm.org has answered 593 requests for consultations. Requests for consultations about pigmented skin lesions were the most frequent, at 222 requests (of which 173 concerned dermoscopy), followed by requests for consultations about non-melanoma skin cancer (35 requests). The remaining 336 requests focused on various other categories of skin disease, such as inflammatory skin disorders, infectious diseases, genodermatoses, vascular lesions, adnexal tumors, cutaneous lymphomas, etc. 

The 3rd European Congress of Teledermatology promoted telederm.org as the official web application for the congress, displaying the application as a practical demonstration of telemedicine. During the three days of the Congress, 245 additional requests were generated by dermatologists operating free consultations from a temporary, walk-in clinic set up in the town center as a public service. Requests sent to telederm.org were immediately answered by an on-line expert. After its successful debut at the 3rd European Congress of Teledermatology, telederm.org is now listed as the official web site of the International Society of Teledermatology (IST) and is also the official web application of the First World Congress of Teledermatology scheduled to convene in Graz in April, 2005.

The telederm.org application

telederm.org is a web application whereby dermatologists, general practitioners or any healthcare workers interested in teledermatology can quickly and easily seek diagnostic advice in dermatology from a pool of expert consultants. Also, healthcare providers interested in dermatology can participate in the discussion forum regarding interesting and unusual cases in clinical dermatology, dermatopathology and dermoscopy. The telederm.org team includes dermatology consultants, a webmaster, who maintains the application software, and a moderator of the discussion forum. Consultants are selected on the basis of their proven track record in medical dermatology, dermatopathology, or dermoscopy. Consultants undergo initial training in the application and participate thereafter in an ongoing quality-assurance program.

Only physicians or healthcare providers are able to register and access the application. After registering, users are given a username and a password with which to access the application and submit requests for consultations. Responses should be available within 72 hours.

All requests are archived in an electronic database, with a personal archive for each user. A user can choose to send a request for consultation only to a selected expert, or he or she can submit a request in an open forum as a "discussion case." In the former situation, the user receives a personal answer, and the interactions remain in a private field. Cases submitted as "discussion cases" are visible to all users, who can review the cases and submit on-line opinions. Every week selected cases are posted in a special forum open to on-line, moderated discussion.

Summary

Equal access to medical care, regardless of social, economic, ethnic and topographic conditions, is a major goal of medical policy today. Telemedicine can assist in achieving this goal by providing rapid access to expert medical consultation. The goal of telederm.org is to develop a best-practice model for teleconsultation using skin diseases as a paradigm.

The telederm.org application offers dermatologists a proven system of easy and affordable access to expert consultation. Through telederm.org, participants from different countries and with different medical specialties are matched with dermatologists who have experience in skin diseases in a multiethnic population. A given skin condition can be diagnosed virtually by many different experts in dermatology, thereby stimulating exchange of knowledge and expertise. By providing an interactive discussion between physicians at the point of care and experts from many different countries, telederm.org seeks to raise the level of competence of physicians and dermatologists at the point of care on a worldwide level. 


Participants to the telederm.org project

· Department of Dermatology, Medical University of Graz, Graz (Austria)
· Department of Dermatology, 1st Teaching Hospital, University of Zhengzhou, Zhengzhou (PR China)
· Department of Dermatology, Charité, Berlin (Germany)
· Department of Dermatology, University of Tuebingen, Tuebingen (Germany) 
· Department of Dermatology, Teheran University of Medical Sciences, Teheran (Iran)
· Department of Dermatology, Second University of Naples, Naples (Italy)
· Department of Dermatology, University of Rome Tor Vergata, Rome (Italy)
· Department of Dermatology, University Medical Center Ljubljana, Ljubljana (Slovenia)
· Department of Dermatology, University of Juba, Khartoum (Sudan)
· Department of Dermatology, Medical University Ankara, Ankara (Turkey)
· Department of Dermatology, University of Makerere, Kampala (Uganda)



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Acknowledgements
The authors thank Barbara J Rutledge, PhD, for the competent editorial collaboration.

Cite as: 
Massone C, Hofmann-Wellenhof R, Gabler G, Dong H, Kaddu S  et al
Global Teledermatology: A specific dermatologic web application for Dermatological Consultation 
Internet Health 2004;3(1):e3
URL: www.internet-health.org/ih200431e03.html 

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