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Cited by 72Telemedicine and Telehealth ImplementationHealthcare Systems and TechnologyCutaneous Melanoma Detection and Management

Lessons learned after a three-year store and forward teledermatology experience using internet: Strengths and limitations

Open access
Lasierra, N., Alesanco, A., Gilaberte, Y., Magallón, R., García, J.·2012·International Journal of Medical Informatics
DOI 10.1016/j.ijmedinf.2012.02.008
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Abstract

Purpose This paper presents a three-year teledermatology evaluation experience. The aim is to explain the methodology followed, present the evaluation results, discuss critically the issues that emerged during the experience and report the main lessons learned.Methods A complete design and evaluation methodology was conducted to fully address significant issues arising from other previous teledermatology experiences. First, system-design requirements and image quality issues were studied. Then, a detailed clinical concordance study was undertaken to determine the accuracy of diagnoses made using teledermatology in order to assess different dermatological clinics. Finally, an impact study on the health system was performed. Furthermore, clinical, technical, social and alignment outcomes were analyzed during the study and at the end of it, in order to understand how emerging factors affected the final setup of the teledermatology system.Results The most important results reported in this study can be summarized as follows. (1) A complete web-based environment for teledermatology support was developed as a result of a dynamic evaluation process with clinical personnel. (2) A total of 120 teleconsultations (82 pediatric and 28 adult) were made during the clinical concordance study. Concordance analysis was carried out for each dermatological disease group. High concordance rates were found in pediatrics for inflammatory dermatoses (76%) and also for adults (75%) with infections and infestations. (3) Physicians were satisfied with the teledermatology system but the time dedicated to consultation in primary care was a limiting factor (19min for each teleconsultation). (4) An extensive discussion about the successful and the limiting aspects of the teledermatology experience revealed the reasons behind the final decision not to proceed with its implementation. It was considered not to be aligned with Health Care Organization (HCO) strategy and consequently did not achieve high-level support for its long-term implementation.Conclusions A high degree of diagnostic accuracy both for pediatric and adult consultations was achieved using the teledermatology system with affordable technical requirements. Its usefulness for filtering dermatological referrals was also demonstrated in the study. Nevertheless, other factors such as the reorganization required for the physicians' time schedule, remuneration issues, absence of EHR (electronic health record) integration and lack of interaction with the HCO were important limiting factors. This led to the conclusion that under the evaluation conditions long-term set-up was not possible. It was also concluded that HCO participation would have been essential for both the evaluation study and the long-term set-up of the system.

AI snapshot

Written from the paper’s full text.

TL;DR

This paper reports a three-year store-and-forward teledermatology evaluation in Aragón, Spain, combining technical development, clinical concordance, and health-system impact assessment. Despite high diagnostic concordance and physician satisfaction, the system was not implemented long-term because of time burden, lack of EHR integration, remuneration/organizational issues, and poor alignment with Health Care Organization strategy.

Key findings

  • In 120 complete concordance consultations (82 pediatric; adult count reported as 28 in the abstract and 38 in the body), high total agreement was found for pediatric inflammatory dermatoses (76%) and adult infections/infestations (83% in Table II; the abstract states 75% for adults).
  • Dermatologists issued a first reliable diagnosis in 64% (77/120) of teleconsultations; teledermatology as a filter tool (first reliable diagnosis plus no second visit) was 42% (50/120), with 90% concordance (45/50) among those.
  • Poor image quality was reported in 24% of total consultations; among 43 cases where no diagnosis was issued, 66% (28/43) were due to poor-quality images. Image quality improved over time: very low quality fell from 17% in the first 60 consultations to 10% in the last 60, and “should be improved” fell from 35% to 17%.
  • Physicians were satisfied (100% satisfied or very satisfied; 9/10 would recommend daily use), but GPs spent 19 minutes per teleconsultation versus 10 minutes for a normal dermatology consultation, and the system was not integrated with patients’ EHR.

Methods

  • Three-year store-and-forward teledermatology experience in Aragón, Spain, using a web application, conventional digital cameras, and a Flash-based image viewer; 20 physicians (4 dermatologists and 16 GPs, including 11 pediatricians) in 3 working groups participated.
  • Clinical concordance study conducted April 2008–July 2010: patients received a teledermatology diagnosis and then a face-to-face consultation within 1 week; concordance was classified as agreement, partial, or disagreement, with questionnaires and descriptive statistics.
  • Impact study measured time spent in primary and specialist care and physician opinion; 10 physicians completed a 10-question acceptability questionnaire.

Limitations

  • The paper states that the main limitations were the extra time required in primary care (nearly 20 minutes per patient), lack of EHR integration, needed reorganization of physician schedules, remuneration issues, technical limitations such as inadequate health-centre facilities/internet access, and lack of HCO involvement/alignment; patient satisfaction was not completed because permanent establishment was not reached.
  • The text makes evident that some subgroup analyses were based on very few cases (e.g., adult “other dermatoses” n=7, genodermatoses n=2, vascular disorders n=5), limiting general conclusions.
  • The text also shows an inconsistency in the adult sample count between the abstract (28 adults) and the body (38 adults), which affects interpretation of the 120-consultation denominator.

Model-written summary. Check it against the paper before relying on it.

Integrity signals

Registry

Crossref · 10.1016/j.ijmedinf.2012.02.008

Cites

38 of 38 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 35 cited sources checked · 0 supported · 0 flagged

  • Findingown data
    § Abstract

    A complete web-based environment for teledermatology support was developed as a result of a dynamic evaluation process with clinical personnel.

    “A complete webbased environment for teledermatology support was developed as a result of a dynamic evaluation process with clinical personnel.”
    Quote in the paperSubstantial claim
  • Findingown data
    § Abstract

    Physicians were satisfied with the teledermatology system.

    “Physicians were satisfied with the teledermatology system but the time dedicated to consultation in primary care was a limiting factor (19 minutes for each teleconsultation)”
    Quote in the paperNot a substantial claim
  • Findingnone given
    § 1. Introduction

    Different problems (technical, organizational and social) did eventually emerge during the study.

    “Different problems (technical, organizational and social) did eventually emerge during the study and finally a long-term setup of the system was not possible.”
    Quote in the paperSubstantial claim
  • Findingown data
    § Abstract

    High concordance rates were found in pediatrics for inflammatory dermatoses (76%).

    “High concordance rates were found in pediatrics for inflammatory dermatoses (76%) and also for adults (75%) with infections and infestations.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: Face-to-face consultation with a dermatologist provides the definitive diagnosis against which teledermatology diagnosis can be compared.
  • Findingown data
    § Abstract

    A total of 120 teleconsultations (82 pediatric and 28 adult) were made during the clinical concordance study.

    “A total of 120 teleconsultations (82 pediatric and 28 adult) were made during the clinical concordance study.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 29
  • Classified as probably not a substantial claim. 29
  • The quote only partly states this claim. 2

  • May combine two claims.

    Findingown data
    § 3.3.2 Diagnosis Consultations

    Tumors (n=24, especially benign n=20) and infections and infestations (n=22) were also very common.

    “Tumors (n=24, especially benign ones n=20), and infections and infestations (n=22) were also very common.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Findingnone given
    § 3.2 Image quality results

    There were significant differences regarding physicians' photography skills.

    “They also reported that there were significant differences regarding physicians' photography skills”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § 3.3.3 Concordance Diagnosis Results

    Lower rates of total agreement were found for other pathologies and some discordant diagnoses (C2).

    “Lower rates of total agreement were found for others pathologies and also some discordant diagnosis (C2).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § 3.3.3 Concordance Diagnosis Results

    Total agreement (C4) for inflammatory dermatoses in adults was not so high and some mismatched diagnoses were delivered (2/16).

    “Note that the total agreement (C4) for inflammatory dermatoses was not so high and also that some mismatched diagnoses were delivered (2/16).”
    Quote in the paperSubstantial claim

  • The quote only partly states this claim.

    Findingown data
    § 5.1 Strengths of the system

    Among the 50 filter-tool cases, concordance (high grade of success) was 90% (45/50).

    “Furthermore, the results showed that when the dermatologist emitted a reliable diagnosis, the total agreement rate was 90%.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data
    § 3.1 Technical architecture results

    Physicians reported investing an average of 2 hours to learn to use the software.

    “They also reported that they had invested an average of 2 hours to properly learn how to use the software.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § 3.1 Technical architecture results

    All physicians completed the technical questionnaires and reported that the system was easy to use, intuitive, and well-adjusted to a clinical setting.

    “All the physicians completed the technical questionnaires and reported that the system was easy to use, intuitive, and well-adjusted to a clinical setting.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § 3.2 Image quality results

    For 17% of the first 60 consultations, the dermatologist reported very low quality images, declining to 10% for the last 60 consultations.

    “In fact, for 17% of the first 60 consultations performed, the dermatologist reported very low quality images while this percentage declined to 10% for the last 60 consultations.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § 3.2 Image quality results

    For 35% of the first 60 consultations, the dermatologist reported that image quality should be improved, dropping to 17% for the last 60 consultations.

    “Furthermore, for 35% of the first 60 consultations, the dermatologist reported that the image quality should be improved while the percentage dropped to 17% for the last 60 consultations.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § 3.3.3 Concordance Diagnosis Results

    Within the 'other dermatoses' group, total agreement (C4) was found for genodermatoses (2/2) and vascular disorders (3/4).

    “Nevertheless, within this group, total agreement (C4) was found for genodermatoses (2/2) and vascular disorders (3/4).”
    • Also stated in: § 4. Discussion of the evaluation and related work · plain
      “In the present study, high rates of concordance were found for genodermatoses (total agreement: 100%) and vascular disorders (total agreement: 75%).”
    Quote in the paperNot a substantial claim

  • The quote only partly states this claim.

    Findingown data
    § 3.3.3 Concordance Diagnosis Results

    High concordance was found in the adult 'other dermatoses' group.

    “High concordance was also found in the 'other dermatoses' group”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given
    § 3.4.2 Impact on Physicians Study

    The limited number of patients that could be scheduled per week in dermatology centres delayed the reliability study.

    “(6) the limited number of patients that could be scheduled per week in dermatology centres delayed the reliability study.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data
    § 3.4.2 Impact on Physicians Study

    Extra time was required to send images and this delayed conventional consultations.

    “(4) extra-time was required in order to send images and this delayed conventional consultations”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingcitation
    § 4. Discussion of the evaluation and related work

    We obtained high rates of concordance for inflammatory dermatoses (75.75%), similar to [12] where 82% was achieved for pediatric rashes.

    “We obtained high rates of concordance for inflammatory dermatoses (75.75%) (which was also the most common referral diagnosis), thus presenting similar outcomes to other studies such as [12] where 82% was achieved for pediatric rashes.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [12] [12] Heffner VA, Lyon VB, Brousseau DC, Holland KE, Yen K. Store-and-forward teledermatology versus in-person visits: a comparison in pediatric teledermatology clinic. J Am Acad Dermatol. 2009 Jun;60(6):956-61. Epub 2009 Apr 11. PMID: 19362751 source

      Not checked in the free run.

  • May combine two claims.

    Findingcitation
    § 4. Discussion of the evaluation and related work

    The agreement rate between GPs and dermatologists was medium (43%), similar to [20] where 48% of total concordance was reported for paediatricians and dermatologists.

    “The agreement rate between GPs and dermatologists was medium (43%), similar to [20] where 48% of total concordance was reported for paediatricians and dermatologists.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites [20] [20] Chen T. S, Goldyne M. E, Mathes E. F. D, Frieden I. J, Gilliam A. E. Pediatric teledermatology: Observations based on 429 consults. J Am Acad Dermatol 2010; 62:61-6). PMID: 19926163 source

      Not checked in the free run.

  • May combine two claims.

    Findingown data
    § 4. Discussion of the evaluation and related work

    Physicians involved in the project declared themselves to be very satisfied with the use of teledermatology and 90% would recommend including teledermatology in clinical routine.

    “Physicians involved in this project declared themselves to be very satisfied with the use of teledermatology and 90% of them would recommend including teledermatology in clinical routine.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given
    § 5. Retrospective analysis

    HCO approval was not finally obtained.

    “HCO approval was not finally obtained.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data
    § 4. Discussion of the evaluation and related work

    From previous consultations, five diagnosis errors were detected, representing 4% of the total, and 45 were totally in agreement.

    “From previous consultations, five diagnosis errors were detected, representing 4% of the total, and 45 were totally in agreement.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingreasoning
    § 5.2 Limitations of the system

    The principal limitations of the teledermatology experience were the time involved and the lack of EHR integration.

    “The principal limitations revealed in the teledermatology experience were the time involved and the lack of EHR integration.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data
    § 5.3 Side effects and additional benefits

    The main reasons given by physicians for decreased usage of the system were the extra time involved and difficulties in performing consultations in health centres.

    “The extra time involved and difficulties in performing consultations in health centres were the main reasons given.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Findingnone given
    § 5.3 Side effects and additional benefits

    Communication between physicians is improved by teledermatology systems.

    “In addition, communication between physicians is improved.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given
    § 6.1 Lessons learned from the evaluation study

    Dynamic collaboration between technical and clinical personnel was a positive factor leading to improvements in the teledermatology experience.

    “It is interesting to note that dynamic collaboration between technical and clinical personnel was a positive factor leading to improvements in the teledermatology experience.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingnone given
    § 6.2 Lessons learned from the project

    The initiative was taken by medical personnel, and the HCO was not involved until the final stage of Step 3.

    “The initiative in this case was taken by medical personnel, and the HCO was not involved until the final stage of Step 3.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Premisecitation
    § 1. Introduction

    The alignment of new information systems with the objectives of Health Care Organizations (HCO) is a key factor for their introduction and long-term success.

    “The alignment of new information systems with the objectives of Health Care Organizations (HCO) is a key factor for their introduction and long-term success.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites [27] [27] Luftman J, Assessing Business-IT alignment Maturity. Communications of the Association for the Information Systems (AIS), 2000; 4(14):1-49

      Not checked in the free run.

    • cites [28] [28] Van de Wetering R, Batenburg R, Versendaal J, Lederman R, Firth L. A balanced evaluation perspective: picture archiving and communication system impacts on hospital workflow, J Digit Imaging, 2006; 19 (Suppl. 1):10-17 PMID:16763932 source

      Not checked in the free run.

  • May combine two claims.

    Study design and conductreasoning
    § 2.3 Clinical Concordance Study

    There were no more exclusion criteria for other patients with dermatological diseases; hence no pre-selection was involved (neither pathological nor in terms of demographic conditions) when performing teledermatology consultations.

    “There were no more exclusion criteria for other patients with dermatological diseases; hence no pre-selection was involved (neither pathological nor in terms of demographic conditions) when performing teledermatology consultations.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § 2.2 Clinical Image: quality and tools

    GPs require some minimum training in clinical photograph acquisition.

    “Nevertheless, GPs do require some minimum training in clinical photograph acquisition.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [30] [30] American Telemedicine Association. Practice guidelines for teledermatology December 2007. source

      Not checked in the free run.

    • cites [31] [31] Jakowenko J. Clinical Photography. J Telemed Telecare .2009; 15: 7-22 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationnone given
    § Abstract

    Other factors such as the reorganization required for the physicians' time schedule, remuneration issues, absence of EHR integration and lack of interaction with the HCO were important limiting factors.

    “Nevertheless, other factors such as the reorganization required for the physicians' time schedule, remuneration issues, absence EHR (electronic health record) integration and lack of interaction with the HCO were important limiting factors.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given
    § 2.3.1 Clinical Concordance study process

    If patients agreed to participate, they signed the consent form authorising the sending of their clinical data outside care centres.

    “If they agreed to participate, they signed the consent form (authorising the sending of their clinical data outside care centres) and the GPs then took photographs of their lesions.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Study design and conductnone given
    § 2.1 Teledermatology software system

    The developed teledermatology system was integrated in a secure environment where confidentiality, privacy and integrity of the exchanged medical data were always guaranteed.

    “The developed system was integrated in a secure environment where confidentiality, privacy and integrity of the exchanged medical data were always guaranteed.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation
    § 1. Introduction

    Bush et al. suggested five steps for aligning information systems with organizational objectives: 1) identify organization objectives; 2) identify organization strategy to cope with the objectives; 3) envision an information system to support organization strategies; 4) gain approval of health centres at a high-level to implement the system; 5) implement the system.

    “Bush et. al. in [29] suggested five steps for aligning information systems with organizational objectives: 1) identify organization objectives; 2) identify organization strategy to cope with the objectives; 3) envision an information system to support organization strategies; 4) gain approval of health centres at a high-level to implement the system; 5) implement the system.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [29] [29] Bush M, Lederer A.L, Li X, Palmisano J, Rao S. The alignment of information systems with organizational objectives and strategies in health care. Int J Med Inform, 2009; 78 (7):446-456. PMID:19307148 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § 1. Introduction

    Alignment theories suggest that as long as a telemedicine system contributes to the achievement of HCO objectives following defined strategic plans, it can be aligned with hospital strategy and its long-term set-up will be possible.

    “Alignment theories suggest that as long as a telemedicine system contributes to the achievement of HCO objectives following defined strategic plans, it can be aligned with hospital strategy and its long-term set-up will be possible.”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [27] [27] Luftman J, Assessing Business-IT alignment Maturity. Communications of the Association for the Information Systems (AIS), 2000; 4(14):1-49

      Not checked in the free run.

    • cites [28] [28] Van de Wetering R, Batenburg R, Versendaal J, Lederman R, Firth L. A balanced evaluation perspective: picture archiving and communication system impacts on hospital workflow, J Digit Imaging, 2006; 19 (Suppl. 1):10-17 PMID:16763932 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning
    § Abstract

    HCO participation would have been essential for both the evaluation study and the long-term set-up of the system.

    “It was also concluded that HCO participation would have been essential for both the evaluation study and the long-term set-up of the system.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation
    § 1. Introduction

    Real-time is seldom required for teledermatology while store-and-forward provides sufficient flexibility in consultation schedules with high rates of accuracy.

    “In general, real-time is seldom required for teledermatology while S&F provides sufficient flexibility in consultation schedules with high rates of accuracy [7,11,12].”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites [7] [7] Du Molin MF, Bullens-Goessens YI, Henquet CJ, Brunenberg DE, de BrunGeraerds DP, Winkens RA, Dirksen CD, Vierhout WP, Neumann HA. The reliability of diagnosis using store-and-forward teledermatology. J Telemed Telecare. 2003;9(5):24952. PMID: 14599326 - source

      Not checked in the free run.

    • cites [11] [11] High WA, Houston MS, Calobrini SD, Drage LA, McEvoy MT. Assessment of the accuracy of low-cost store and forward teledermatology consultation. J Am Acad Dermatol. 2000 May;42(5 Pt 1):776-83. PMID: 10775853 source

      Not checked in the free run.

    • cites [12] [12] Heffner VA, Lyon VB, Brousseau DC, Holland KE, Yen K. Store-and-forward teledermatology versus in-person visits: a comparison in pediatric teledermatology clinic. J Am Acad Dermatol. 2009 Jun;60(6):956-61. Epub 2009 Apr 11. PMID: 19362751 source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationreasoning
    § 3.2 Image quality results

    Some physicians would require a specific training course in addition to the guidelines provided.

    “we determined that in addition to the guidelines provided, some physicians would require a specific training course.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § 4. Discussion of the evaluation and related work

    A wide range of concordance rates from 54% to 89% have been reported in the literature.

    “A wide range of concordance rates from 54% to 89% have been reported in the literature [7,11,25,35].”
    Quote in the paperNot a substantial claim0 of 4 sources checked
    • cites [7] [7] Du Molin MF, Bullens-Goessens YI, Henquet CJ, Brunenberg DE, de BrunGeraerds DP, Winkens RA, Dirksen CD, Vierhout WP, Neumann HA. The reliability of diagnosis using store-and-forward teledermatology. J Telemed Telecare. 2003;9(5):24952. PMID: 14599326 - source

      Not checked in the free run.

    • cites [11] [11] High WA, Houston MS, Calobrini SD, Drage LA, McEvoy MT. Assessment of the accuracy of low-cost store and forward teledermatology consultation. J Am Acad Dermatol. 2000 May;42(5 Pt 1):776-83. PMID: 10775853 source

      Not checked in the free run.

    • cites [25] [25] Warshaw E. M et al. Accuracy of teledermatology for pigmented neoplasms. J Am Acad Dermatol. 2009 Nov;61(5):753-65. Epub 2009 Aug 12. PMID: 19679375 source

      Not checked in the free run.

    • cites [35] [35] Ishioka P, Tenório JM, Lopes PR, Yamada S, Michalany NS, Amaral MB, Pisa IT, Hirata SH, Almeida FA. A comparative study of teledermatoscopy and face-to-face examination of pigmented skin lesions. J Telemed Telecare 2009;15(5):221-5. PMID: 19590026 source

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Interpretationown data
    § 4. Discussion of the evaluation and related work

    Given this high concordance, the teledermatology system could be useful for filtering referrals of inflammatory dermatoses.

    “Given this high concordance, the teledermatology system could be useful for filtering referrals of inflammatory dermatoses (being diagnosed by teledermatology).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation
    § 4. Discussion of the evaluation and related work

    In [11], concordance ranged in general between 81%-89%, specifically 100% for infestations and 77-100% for inflammatory dermatoses.

    “in [11], where low-cost resources were also used, concordance ranged in general between 81%-89%, specifically 100% for infestations and 77-100% for inflammatory dermatoses (depending on the teledermatologist).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [11] [11] High WA, Houston MS, Calobrini SD, Drage LA, McEvoy MT. Assessment of the accuracy of low-cost store and forward teledermatology consultation. J Am Acad Dermatol. 2000 May;42(5 Pt 1):776-83. PMID: 10775853 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data
    § 4. Discussion of the evaluation and related work

    Although image quality improved and good agreement rates were found, GPs still need to improve their level of clinical image acquisition.

    “Although image quality improved during the experience and good rates of agreement were found in the clinical concordance study, the results showed that GPs still need to improve their level of clinical image acquisition.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning
    § 4. Discussion of the evaluation and related work

    The difference between our time results and those of [8] is mainly due to pediatric image acquisition difficulties and the use of a specific web application rather than email.

    “This is mainly due to the fact that in pediatrics, the image acquisition process is not as easy as with adults because children tend to have difficulties in keeping still. In addition, in our case a specific web application was used for teledermatology and not e-mail as in the previous work [8].”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [8] [8] Van den Akker. Th W, Reker C H M, Knol A, Post J, Wilbrink J, Van der Veen J P W. Teledermatology as a tool for communication between general practitioners and dermatologists. J Telemed Telecare. 2001;7(4):193-8. PMID: 11506753 source

      Not checked in the free run.

    • Rests on an assumption: Children tend to have difficulties in keeping still.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationnone given
    § 5.1 Strengths of the system

    The fact that the teleconsultation procedure was easy contributed to encouraging physicians' participation.

    “There is no doubt that the fact that the teleconsultation procedure was so easy contributed to encouraging physicians' participation.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing), S4 (based).

    Interpretationnone given
    § 4. Discussion of the evaluation and related work

    The main advantage of the system is that all information is electronically available.

    “The main advantage of the system is that all information is electronically available.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationnone given
    § 5.1 Strengths of the system

    Clinical and technical personnel working together with a common agenda was essential to our teledermatology experience.

    “Clinical and technical personnel working together with a common agenda was essential to our teledermatology experience.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § 4. Discussion of the evaluation and related work

    Similar outcomes for time requirements were found in [9], where 11.5 minutes were calculated for a teledermatology consultation in primary care centres.

    “Similar outcomes for time requirements were found in [9], were 11.5 minutes were calculated for a teledermatology consultation in primary care centres.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [9] [9] Berghouta R. M, Eminovíc N, De Keizera N. F, Birnieb E. Evaluation of general practitioner's time investment during a store-and-forward teledermatology consultation. Internationa. Int J Med Inform. 2007 Dec;76 Suppl 3:S384-91. Epub 2007 May 25. PMID: 17532256 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning
    § 5.1 Strengths of the system

    The main strengths of the teledermatology setup were found in the multidisciplinary collaboration, the clinical concordance study and the degree of physicians' satisfaction.

    “The main strengths of the teledermatology setup were found in the multidisciplinary collaboration, the clinical concordance study and the degree of physicians' satisfaction.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § 5.1 Strengths of the system

    This approach is in line with other reported studies on telemedicine systems emphasising that successful implementation is a final outcome of a dynamic process where the interaction among all factors must be assessed to optimize the system.

    “This approach is in line with other reported studies on telemedicine systems emphasising that successful implementation is a final outcome of a dynamic process where the interaction among all factors (clinical, social, technical and organizational) must be assessed in order to optimize the system [37,38].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [37] [37] Wears RL, Berg M. Computer technology and clinical work: Still waiting for Godot. JAMA 2005; 293(10):1261-1263 source

      Not checked in the free run.

    • cites [38] [38] Woods DD. Designs are hypotheses about how artifacts shape cognition and collaboration. Ergonomics,1998;41:168-173. source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data
    § 4. Discussion of the evaluation and related work

    For inflammatory dermatoses and infection cases, concordance agreement rates were relatively high, so teledermatology could be very useful for diagnosis confirmation in these cases, avoiding patient transfers.

    “We also determined that, for inflammatory dermatoses and infection cases, concordance agreement rates were relatively high, thus teledermatology could be very useful for diagnosis confirmation in these cases, avoiding patient transfers.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data
    § 4. Discussion of the evaluation and related work

    Regarding patient satisfaction, an impact study was not completed because it was due to be carried out after permanent establishment of the teledermatology system, and this phase was not reached.

    “Regarding patient satisfaction, an impact study was not completed since this was due to be carried out after the permanent establishment of the teledermatology system. This phase was not reached in our experience.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationcitation
    § 4. Discussion of the evaluation and related work

    As reported in [9], implementation of integration with EHR would reduce the time invested by GPs for teledermatology consultations.

    “As was also reported in [9], its implementation would certainly reduce the time invested by GPs for teledermatology consultations.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [9] [9] Berghouta R. M, Eminovíc N, De Keizera N. F, Birnieb E. Evaluation of general practitioner's time investment during a store-and-forward teledermatology consultation. Internationa. Int J Med Inform. 2007 Dec;76 Suppl 3:S384-91. Epub 2007 May 25. PMID: 17532256 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationown data
    § 5. Retrospective analysis

    Although the four relevant factors identified as essential were successfully handled and the system was both technically and clinically viable, some problems emerged and limitations were identified which required solutions before HCO would consider long-term set-up.

    “Although the four relevant factors identified as being essential to the development and evaluation of the system were successfully handled and the system was both technically and clinically viable, some problems did eventually emerge and limitations were identified which required solutions before the HCO would consider the long-term set-up of the teledermatology system.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationreasoning
    § 4. Discussion of the evaluation and related work

    The cautious approach of physicians set a limitation on the use of teledermatology, and its usage for filtering referrals was rated at 42%.

    “The cautious approach of physicians thus set a limitation on the use of teledermatology, and its usage for filtering referrals was rated at 42%.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Interpretationreasoning
    § 5.1 Strengths of the system

    This cooperation led to the development of a teledermatology environment adapted to the clinical setting.

    “This cooperation led to the development of a teledermatology environment adapted to the clinical setting.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § 6.2 Lessons learned from the project

    Alignment of information technology systems with organizational and business strategies in hospitals is a critical key factor in the successful long-term implementation of a telemedicine system.

    “Alignment of information technology systems with organizational and business strategies in hospitals has been identified as a critical key factor in the successful implementation (long-term set-up) of a telemedicine system [27,28].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [27] [27] Luftman J, Assessing Business-IT alignment Maturity. Communications of the Association for the Information Systems (AIS), 2000; 4(14):1-49

      Not checked in the free run.

    • cites [28] [28] Van de Wetering R, Batenburg R, Versendaal J, Lederman R, Firth L. A balanced evaluation perspective: picture archiving and communication system impacts on hospital workflow, J Digit Imaging, 2006; 19 (Suppl. 1):10-17 PMID:16763932 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § 5.3 Side effects and additional benefits

    The need for additional payment to physicians was reported in [2].

    “The need for additional payment to physicians was also reported in [2] where, as in our study, a list of facts of daily routine consultations were detected to condition teledermatology failure or success.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [2] [2] Oakley A, Rademaker M, Duf.ll M. Teledermatology in the Waikato region of New Zealand. J Telemed Telecare. 2001;7 Suppl 2:59-61. PMID: 11747661 source

      Not checked in the free run.

  • May combine two claims.

    Interpretationreasoning
    § 6.2 Lessons learned from the project

    Lack of HCO involvement caused delays and difficulties during setup and prevented the system from being evaluated from the patients' point of view in the final stage of Step 3.

    “Eventually, this lack of HCO involvement caused delays and difficulties during the setup and prevented the system from being evaluated from the patients' point of view in the final stage of Step 3 of the study.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing).

    Premisecitation
    § 6.2 Lessons learned from the project

    Good telemedicine implementations are developed after a process where the dynamic interaction among a combination of socio-technical factors is optimized.

    “As suggested in [37], good telemedicine implementations are developed after a process where the dynamic interaction among a combination of socio-technical factors is optimized.”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites [37] [37] Wears RL, Berg M. Computer technology and clinical work: Still waiting for Godot. JAMA 2005; 293(10):1261-1263 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation
    § 5.3 Side effects and additional benefits

    The efficacy and viability of teledermatology for medical training and educational benefits in treatment plans has already been demonstrated in other studies.

    “Besides, the efficacy and viability of teledermatology for medical training and educational benefits in treatment plans has already been demonstrated in other studies [8, 39].”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites [8] [8] Van den Akker. Th W, Reker C H M, Knol A, Post J, Wilbrink J, Van der Veen J P W. Teledermatology as a tool for communication between general practitioners and dermatologists. J Telemed Telecare. 2001;7(4):193-8. PMID: 11506753 source

      Not checked in the free run.

    • cites [39] [39] Shaikh N, Lehmann CU, Kaleida PH, Cohen BA. Efficacy and feasibility of teledermatology for paediatric medical education. J Telemed Telecare. 2008;14(4):2047. PMID: 18534955 source

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable).

    Interpretationreasoning
    § 6.2 Lessons learned from the project

    These obstacles could have been avoided if the HCO had been involved in the evaluation of the project.

    “These could have been avoided if the HCO had been involved in the evaluation of the project.”
    Quote in the paperNot a substantial claim
57 of 57

  • The paper relies on this without support.

    Image quality greatly influences dermatologists' confidence in providing a diagnosis and is thus a determining factor in the effectiveness of teledermatology.

    “Image quality greatly influences dermatologists' confidence in providing a diagnosis and is thus a determining factor in the effectiveness of teledermatology.”

  • The paper relies on this without support.

    Store-and-forward teledermatology systems are less financially and technologically demanding than real-time setups.

    “These systems do not require real-time interaction between the parties, and are less financially and technologically demanding than real-time setups.”

  • The paper relies on this without support.

    Images constitute the major source of information for dermatologists when making a teledermatology diagnosis.

    “As images constitute the major source of information for dermatologists when making a teledermatology diagnosis”

  • The paper relies on this without support.

    Face-to-face consultation with a dermatologist provides the definitive diagnosis against which teledermatology diagnosis can be compared.

    “After a period of no longer than 1 week, patients were referred to a face-to-face consultation with the same dermatologist to obtain a definitive diagnosis (see Figure 2).”

  • The paper relies on this without support.

    The pathologies manifested in pediatric and adult age groups are not the same.

    “We examined separately and in detail diseases for pediatrics and adults because the pathologies manifested in the age groups are not the same.”

  • The paper relies on this without support.

    Age could influence certain issues in the teleconsultation performance.

    “Furthermore, age could influence certain issues in the teleconsultation performance.”

  • The paper relies on this without support.

    Acceptability on the part of clinical personnel substantially affects the success of telemedicine systems.

    “As is widely known, acceptability on the part of clinical personnel substantially affects the success of telemedicine systems.”

  • The paper relies on this without support.

    A common EHR between primary and specialist care has not yet been implemented in health centres in Aragón.

    “It should be noted that our system was not integrated with the patients' EHR because a common EHR between primary and specialist care has not yet been implemented in health centres in Aragón.”

  • The paper relies on this without support.

    Children tend to have difficulties in keeping still.

    “because children tend to have difficulties in keeping still.”

  • The paper relies on this without support.

    The conditions were not the same in all cases and the skin lesions studied were not the same.

    “It should be noted that the conditions were not the same in all cases and the skin lesions studied were not the same.”
10 of 10

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Increased clinician workload and the lack of a definitive reimbursement model cause asynchronous teledermatology to be a substantial burden or gamble for many practices.

    “Furthermore, increased clinician workload and the lack of a definitive reimbursement model cause asynchronous teledermatology to be a substantial burden or gamble for many practices [54-56].”

    From Store-and-Forward Images in Teledermatology: Narrative Literature Review (2022) · cites this paper as [54]

    Sections 5.2 and 5.3 report extra clinician time and workload, and say physicians would expect additional payment for teleconsultations. Section 6.2 identifies workloads and remuneration as implementation limitations, but the paper does not establish a lack of a definitive reimbursement model or characterize asynchronous teledermatology as a gamble for many practices. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • Diagnostic accuracy of tele-dermatology varies widely, with reported rates as high as 80% and as low as 43%.

    “Research indicates it is an efficient and appropriate health service, with two of the most recently published studies citing the accuracy of diagnosis rates at 80% (Wilson and Maeder, 2015). However, some studies have reported the diagnostic accuracy of tele-dermatology as low as 43% (Lasierra et al., 2012).”

    From Patient and practitioner satisfaction with tele-dermatology including Australia’s indigenous population: A systematic review of the literature (2016) · cites this paper as Lasierra et al., 2012

  • In 66% of cases, the treating dermatologist was unable to offer a confident diagnosis and required higher quality images.

    “A 2-year study published in 2012 reported that in 66% of cases, the treating dermatologist was unable to offer a confident diagnosis and require higher quality images (Lasierra et al., 2012).”

    From Patient and practitioner satisfaction with tele-dermatology including Australia’s indigenous population: A systematic review of the literature (2016) · cites this paper as Lasierra et al., 2012

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Abstract age groups do not total 120 consultations

    Minor

    The abstract reports 82 pediatric and 28 adult consultations, which sum to 110 rather than 120. The patient-demographics section instead reports 38 adult consultations.

    Reported 120 · recomputed 110

  • Adult 'other dermatoses' group has conflicting counts

    Minor

    The discussion says there were six adult consultations in this group, whereas Tables I and II each list seven.

  • Adult infection concordance is reported as both 75% and 83%

    Minor

    The abstract gives 75% concordance for adults with infections and infestations, while Table II gives 83% total agreement for that group.

3 of 3

Cites

Flagged first, then by citations

Research works printed but not linked: 1

  1. Jutra, 1959, Teleroentgendiagnosis by means of videotape recording, Am. J. Roentgenol., 82, 1099

Cited by

Sorted by citations

Related

Authors
Lasierra, N., Alesanco, A., Gilaberte, Y., Magallón, R., & García, J.
Affiliations
  • Universidad de Zaragoza (ES)
  • Hospital General San Jorge (ES)
ORCID
Venue
International Journal of Medical Informatics
Publisher
Elsevier BV
Published
2012-05
Volume
81
Issue
5
Pages
332-343
ISSN
1386-5056 (ISSN-L)
DOI
10.1016/j.ijmedinf.2012.02.008
OpenAlex
W2071565461
Cited by
72
References
38
Citations by year
2026: 3 · 2024: 5 · 2023: 8 · 2022: 3 · 2021: 5 · 2020: 10 · 2019: 2 · 2018: 1 · 2017: 10 · 2016: 12 · 2015: 10 · 2014: 2 · 2012: 1
FWCI
4.02
Type
journal article
Language
en
Open access
Licence
Locations
  • International Journal of Medical Informatics (publishedVersion)
  • PubMed (publishedVersion)
  • Zaguan (University of Zaragoza Repository) (submittedVersion, cc-by-nc-nd)
Topics
  • Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Telemedicine and Telehealth Implementation
  • Social Sciences › Business, Management and Accounting › Organizational Behavior and Human Resource Management › Healthcare Systems and Technology
  • Health Sciences › Medicine › Oncology › Cutaneous Melanoma Detection and Management
Keywords
teledermatology, store-and-forward telemedicine, dermatological diagnosis, clinical concordance, pediatric dermatology, physician satisfaction, electronic health record integration, image quality, health system impact, inflammatory skin diseases
MeSH terms
Adolescent, Adult, Aged, Aged, 80 and over, Child, Child, Preschool, Dermatology, Female, Humans, Infant, Male, Middle Aged, Skin Diseases, Reproducibility of Results, Observer Variation, Telemedicine, Remote Consultation, Young Adult, Remuneration

About these checks

Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.

Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-10.

Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-10.

Statistics and arithmetic are recomputed, not judged.

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