Teledermatology for Diagnosis and 

Management of Skin Conditions:

A Systematic Review of the Evidence

Erin M. Warshaw MD MS

Chief, Dermatology Section

Assoc Professor , Dermatology UMN

Core Investigator, HSRD CCDOR

Evidence-based Synthesis Program

Minneapolis VA Medical Center
RESEARCH TEAM

Nancy Greer, PhD

Yonatan Hillman, BA

Emily Hagel, MS; 

Roderick MacDonald, MS

Indulis Rutks, BS

Timothy Wilt, MD, MPH

ESP Program Director
TECHNICAL EXPERT PANEL

Robert Delavalle, MD, PhD

VA Eastern Colorado Health Care System

Denver, CO

Dennis Oh, MD

San Francisco VA Medical Center

San Francisco, CO

John Whited, MD, MHS

Harry S. Truman Memorial VA Medical Center

Columbia, MO
EVIDENCE-BASED SYNTHESIS PROGRAM 

(ESP)

 Funded by Health Services Research and Development 

(HSR&D)

 Purpose: Timely, focused evidence reviews to support 

VA policy and practice and to set directions for future 

research

 Veteran and VA-system focused

 Products: 

Evidence synthesis reports

Succinct briefs for managers and leadership

Web Site: 

http://www.hsrd.research.va.gov/publications/esp
OBJECTIVES 

 Summarize evidence for diagnostic / management 

accuracy and concordance for teledermatology as 

compared to usual care 

 Review data on clinical outcomes, costs and key 

implementation factors in teledermatology
TELEDERMATOLOGY

LIVE INTERACTIVE STORE AND FORWARD

Univ of MN, Mercer Univ, US Military web sites
BACKGROUND

 Store and forward (SAF) more widely used in VA*

 44% (19/43) of responding VA derm chiefs use TD

 Of those, 89% (17 of 19) use SAF

 1 live interactive (LI) 

 1 both SAF and LI

 Despite implementation, info on diagnostic and 

management accuracy and concordance, costeffectiveness, and impact on clinical management and 

patient outcomes are not well understood

*Informal survey of VA dermatology chiefs, December 2009
KEY QUESTIONS – DIAGNOSIS & 

MANAGEMENT

 1. How does the accuracy and concordance of 

teledermatology compare to usual care (in-person 

dermatology) for the diagnosis of skin conditions?

 2 How does the accuracy and concordance of 

teledermatology compare to usual care (in-person 

dermatology) for the management of skin conditions?
KEY QUESTIONS - OUTCOMES

 3. How do clinical outcomes of teledermatology 

compare to usual care (in-person dermatology) for skin 

conditions?

 4. How does the cost of teledermatology compare to 

usual care (in-person dermatology)?

 5. What are the key structural and process elements 

associated with successful implementation of 

teledermatology and what are the barriers?
METHODS

 Topic nominated by Center for Chronic Disease Outcomes 

Research (CCDOR), Minneapolis VAMC

 Key questions developed with TEP

 Literature search (MEDLINE, Cochran Trials Registry, 

PubMed) for:

 Clinical trials, systematic reviews, cost studies, 

implementation papers

 1990 to June 2009

 Human subjects

 Search terms: remote consult/consultation, electronic 

mail, telecommunications, telemedicine, telepathology, 

dermatology, teledermatology
METHODS

 Inclusion Criteria: 

 SAF or LI in English

 controlled trial for Key Questions 1 and 2 (diagnosis, management)

 Exclusion Criteria: 

 teledermatology using mobile phones

 non-teledermatology settings

 dermatopathology

 computer-aided diagnoses only

 survey studies with outcomes not related to questions

 teledermatology as an educational tool

 technology assessment only

 remote monitoring of known diagnoses

 patient-generated photos and/or history (no provider)

 studies with one diagnosis only or only acne or warts

 pediatric population only
METHODS

 Data extracted by 2 research associates , verified by PI 

 Quality Assessment of Diagnostic Accuracy Studies 

(QUADAS)* instrument used to assess study quality of 

studies related to diagnostic accuracy and concordance

 Results presented by outcome and method of outcome 

reporting

 stratified by SAF or LI technology

 weighted mean differences where appropriate (limited 

pooling due to heterogeneity)

*Whiting et al., BMC Medical Research Methodology, 2003
RESULTS

Search Result=657 

References

Abstracts Excluded=473

Full Text Review=184

Full Text Excluded=100

Included Studies=85 Recent Publication=1

Diagnosis/Management 

Questions (1 ,2) =50 

Outcomes Questions 

(3, 4, 5)=26
DEFINITION - DIAGNOSTIC ACCURACY

 Match of TD or CD diagnosis with gold standard 

diagnosis (histopathology or other laboratory test)

 Aggregated

 match of primary or differential diagnoses with gold 

standard diagnosis 

 Primary

 match of primary diagnosis with gold standard diagnosis 
DEFINITION - MANAGEMENT ACCURACY

 Match of TD or CD management plan with gold 

standard management plan
DEFINITIONS - CONCORDANCE

 Diagnostic concordance:

 Aggregated - agreement of TD primary or differential 

diagnoses with CD primary or differential diagnosis 

 Primary - agreement of primary TD diagnosis with primary 

CD diagnosis 

 Management concordance:

 agreement of TD and CD management plans
Results – Q1,2 Diagnosis 

&Management

41 SAF studies (42 publications)

 40 repeated measures studies, 1 randomized trial

 12 U.S., 9 U.K., 6 Italy, 4 Spain, 3 Australia/New Zealand, 

2 Turkey

 5 studies - U.S. Military Personnel or Veterans

 12-882 subjects per study

 Mean age=53 years (19 studies)

 43% female (21 studies)

 93% Caucasian (5 studies)

 Rashes and lesions (14 studies)

 Lesions only (22 studies)
QUADAS RESULTS SAF

1 3

3 8

3 6

1 0

8

2 2

3 0

2 0

1

3

1

0

5

1 0

1 5

2 0

2 5

3 0

3 5

4 0

Selection Index Test Reference Test Data Analysis

#

o

f

S

t

u

d

i

e

s

Yes

Unclear

No

RESULTS – DIAGNOSTIC ACCURACY 

SAF

TD Accuracy vs. CD Accuracy, Weighted 

Mean Difference* 

Aggregated Diagnostic Accuracy = -19% 

range: -28% to 18%

6 studies 

*Teledermatology minus Usual Care

RESULTS – DIAGNOSTIC ACCURACY SAF

TD Accuracy vs. CD Accuracy, Weighted Mean Difference* 

Primary Diagnostic Accuracy = -11% 

range: -54% to 11%

11 studies

Primary Diagnostic Accuracy, Pigmented Lesions 

Only = -5% 

range: -9% to 11%

6 studies

*Teledermatology minus Usual Care
OTHER RESULTS – DIAGNOSTIC ACCURACY

Kappa Statistic SAF:

Teledermatology k = 0.44 to 0.94 (4 studies)

Usual Care k = 0.52 to 0.70 (1 study)

Sensitivity SAF 0.91 (1 study)

Specificity SAF 0.95 (1 study)

Live Interactive (1 study)

Aggregated diagnostic accuracy

Teledermatology=73% Usual Care=64%
RESULTS – DIAGNOSTIC CONCORDANCE SAF

Primary Concordance

Pigmented skin lesions 91% (1 study)

Skin lesions 53-80% (5 studies)

General studies 46-88% (14 studies)

Aggregated Concordance

Skin lesions 64-100% (4 studies)

General studies 60-100% (10 studies)


OTHER RESULTS – DIAGNOSTIC 

CONCORDANCE

Kappa statistic SAF k = 0.71 to 0.93 (4 studies)

Sensitivity SAF 0.88-1.00 (3 studies)

Specificity SAF 0.39-0.98 (3 studies)

Live Interactive

Aggregated 78-99% (5 studies)

Primary 57-78% (7 studies)

Kappa statistic k = 0.62-0.79 (2 studies)
RESULTS – MANAGEMENT SAF

Accuracy 

Teledermatology 75.3% vs. Usual Care 75.9%

Weighted Mean Diff* = -0.6% 

range: -5% to 5%

2 studies

*Teledermatology minus Usual Care

OTHER RESULTS – MANAGEMENT

Concordance

Percent concordant 55-96% (8 studies)

Kappa statistic k = 0.68-0.75 (4 studies)

Sensitivity & Specificity 1.0 (1 study)

Live Interactive

Percent Concordant 64-75% (3 studies)

Kappa statistic k = 0.71 (1 study)
CONCLUSIONS – DIAGNOSIS & 

MANAGEMENT

1. Diagnostic accuracy of in-person dermatology is better 

than SAF teledermatology.

2. Diagnostic concordance of SAF teledermatology with 

in-person dermatology is acceptable.

3. There is limited data on management accuracy; two 

studies show equivalence

4. Management concordance is moderate to very good. 
KEY QUESTION 3 – CLINICAL COURSE

Three studies (2 SAF, 1 LI)

- two suggested more favorable clinical course following 

TD compared to UC 

- third study (VA/DoD n=508) reported no difference

Different methods for determining clinical course

- clinic visit, photos, questionnaire

Clinical course assessed at different time points

- first clinic visit, 4 months, 6 months
PATIENT SATISFACTION

Four SAF studies with usual care comparison group

*randomized controlled trial

**VA studies

Teledermatology Usual Care

3.8/5 (5 point scale)* 3.8/5 (5 point scale)*

84% satisfied overall* 87% satisfied overall*

86% very satisfied** 98% very satisfied**

79% excellent or very good** 78% excellent or very good**
PATIENT PREFERENCE

Four SAF studies

*randomized controlled trial **VA studies

Similar findings for live interactive studies

Teledermatology Usual Care

76% preferred TD over waiting for 

UC*

42% preferred TD over UC** 37% preferred UC over TD**

68% TD as good as UC 40% prefer UC to TD

42% preferred TD over waiting for 

UC

38% prefer UC 
CLINIC VISITS AVOIDED

SAF: % of pts not requiring derm clinic visit (2 studies)

Percentage of visits avoided in studies with no 

comparison group: 12.8% to 53.3% (7 studies)

LI: 14% and 1% differences reported (2 studies)

72.0% did not need follow-up (1 study)

Teledermatology Usual Care Difference

39.0% 18.3% 20.7%

66.0% 38.0% 28.0%
SUMMARY – CLINICAL OUTCOMES

1. There is insufficient data to determine whether 

clinical course is impacted by SAF teledermatology vs. 

in-person dermatology.

2. Waiting time for usual care (in-person dermatology) 

appointments was a factor in patient preference for 

teledermatology.

3. In-person dermatology visits can be avoided when 

teledermatology is used.
KEY QUESTION 4: COST 

 SAF (3 studies)

 1 VA (Whited 275 pts RCT)

 cost-effective but not cost-saving

 1 DoD (Pak 698 pts RCT)

 cost savings of $32/pt accounting for lost productivity

 LI (6 studies)

 2 US (Burgiss 87 pts; Armstrong 451 TD visits)

 cost less or was cost efficient, if pts had long travel or if 

met criteria for volume and usual care costs

 LI vs. SAF (1 study, UK; Loane 102 pts):

 SF less expensive but less clinically efficient than LI
KEY QUESTION 4: SUMMARY - COST

 Limited by various parameters and perspectives 

(societal, health service or patient)

 Most found telederm to be cost effective if:

 Far patient distance

 High telederm volume

 High costs of usual care
KEY QUESTION 5: BARRIERS AND KEY 

ELEMENTS OF SUCCESSFUL 

IMPLEMENTATION

 Lessons learned from mature functioning 

teledermatology systems

 Descriptions of programs

 Finch: longitudinal study of 12 TD services in UK

 MDs, nurses, pts, PCPs, administrators, technologists

 “the original...vision of how TD would be utilized, as a 

technological fix for long waiting lists and consultant 

shortages, failed to be realized.”

 General recommendations – Pak military
EVALUATE THE SETTING & DEFINE 

OBJECTIVES

 Intrasite (Site with dermatology): triage

 Intersite (Site with access to distant VA derm clinic): 

decrease travel, specialist costs

 New Service (Site with no VA derm access): 

decrease outsourcing costs, access
UNDERSTAND ORGANIZATIONAL ISSUES

 Intrasite & Intersite

 Derm workload stable

 Primary care workload increases

 New Site

 Workload increases for both derm and primary care

 Outsource costs for procedures still needed
EVALUATE & PROVIDE REQUIRED 

RESOURCES

 Intrasite & Intersite:

 liquid nitrogen 

 ? support for minor procedures – KOH, scabies prep

 otherwise TD simply triage, only eliminating visits for benign 

growths or simple rashes

 Informal survey - 3 sites d/c’ed TD because most pts needed 

to come to the clinic anyway

 New Site:

 NP or PA with dermatology training important

 Biopsies, KOH, scabies prep,

 On site surgical resources vs. outsourcing for malignancies
COST ANALYSIS, ASSESS ALTERNATIVES

 Cost of TD is mostly personnel, not equipment

 Imager 

 Consult manager

 Likely to fail if primary care MD serves in these roles

 Evaluate needs

 If high volume of skin cancer, TD may not be cost-saving

 Compare TD costs to costs of consultant dermatologist, 

dermatology resident, transportation services
OBTAIN ORGANIZATIONAL SUPPORT

 Medical Center Leadership

 Primary Care – “market” educational benefit

 Surgical Subspecialties

 Dermatology

 Pharmacy

 Intersite and New Service

 Add’l derm meds, CPRS quick orders

 Important to incorporate TD into normal oper
PROVIDE SPECIFIC TD TRAINING

 Imager

 Resources 

 American Telemedicine Association

 http://www.americantelemed.org/i4a/pages/index.cfm?pageid=3325

 VA intranet

 http://vaww.telehealth.va.gov/telehealth/sft/tdrm/index.asp

 American Academy of Dermatology Position Statement

 http://www.aad.org/Forms/Policies/Uploads/PS/PS-Telemedicine%206-15-07.pdf

 Hands on training, usually by dermatologist

 Periodic refresher training
IMPORTANCE OF ONGOING SUPPORT

 TD more than equipment 

 Personnel

 Refresher training

 Upgrades

 Periodic evaluation

 Travel
SUMMARY – IMPLEMENTATION

1. Important 

2. Identifying key factors for success 

and barriers are highly dependent 

on intended setting and specific 

sites
OVERALL CONCLUSIONS

1. Diagnostic accuracy of in-person dermatology is better 

than SAF teledermatology

2. Diagnostic concordance of SAF teledermatology with 

in-person dermatology is acceptable

3. Management concordance is moderate to very good

4. Limited data on management accuracy, clinical 

outcomes

5. Pt satisfaction/preference good; dep on distance

6. Cost-effectiveness also dep on cost usual care, 

distance, & volume 

7. Many key factors in planning implementation
THANK YOU FOR YOUR ATTENTION!

COMMENTS, QUESTIONS 

WELCOME !