Portal de Periódicos da CAPES

Barriers to mobile teledermoscopy in primary care

2013; Elsevier BV; Volume: 69; Issue: 5 Linguagem: Inglês

10.1016/j.jaad.2012.10.039

1097-6787

Joseph T. Chao, Lois J. Loescher, H. Peter Soyer, Clara Curiel‐Lewandrowski,

Digital Imaging in Medicine

To the Editor: Primary care providers (PCPs) now can use mobile teledermoscopy (MT) to evaluate concerning skin lesions. Technologic advances in smartphone cameras permit the capture of high-resolution skin lesion images. PCPs in clinical settings serviced by mobile networks can submit these images and patient information for remote evaluation by a teledermatologist and receive timely feedback. Dermatoscope attachments and applications (app) (Table I) are available for the iPhone 3GS and 4/4S mobile digital devices. These attachments exploit iPhone optics to create a mobile teledermatoscope, allowing visualization of lesion images with superior lighting and focus.Table IiPhone dermatoscope attachmentsAttachmentDermScopeHandyscopeDermlite Connection KitCompanyCanfield Scientific Inc.FotoFinder Systems GmBH3Gen LLCLocationFairfield, New JerseyBad Birnbach, GermanySan Juan Capistrano, CaliforniaDeviceiPhone 4/4SiPhone 3GS,∗Attachments for iPhone 3GS and 4/4S are not inter-compatible. 4/4SiPhone 4/4S Light settings1.Cross-polarized LED2.Flat white LEDPolarized LED light1.Cross-polarized LED†Dermlite dermatoscope: a) DLI; b) DLII models; c) DLIII.2.Nonpolarized light†Dermlite dermatoscope: a) DLI; b) DLII models; c) DLIII.App feature1. Patient profile1. Patient profileNo app available2. E-mail2. E-mail3. Localization3. Localization4. Ruler4. Ruler5. Image comments5. Image comments6. Encrypted and password-protected app storage7. Secure communication—SSLSpecification1.Built-in rechargeable battery•Battery time unknown•Recharge time 4.5 hoursBuilt-in rechargeable battery—8 hours of running time1.Built-in rechargeable lithium ion battery†Dermlite dermatoscope: a) DLI; b) DLII models; c) DLIII.2.Sliding iPhone 4/4S case3.28-mm adaptor ring for DLI, DLII, or DLIII†Dermlite dermatoscope: a) DLI; b) DLII models; c) DLIII.2.Adaptor cone w/wo contact glass plateSystem featuresImage server transfer support onlyeDermoscopy—“Fotofinder Hub” cloud storage•Second-opinion options from telederoscopists•Organization and management of images in personal webspace•Synchronization of multiple mobile devicesNone∗ Attachments for iPhone 3GS and 4/4S are not inter-compatible.† Dermlite dermatoscope: a) DLI; b) DLII models; c) DLIII. Open table in a new tab MT has utility for managing psoriasis,1Frühauf J. Schwantzer G. Ambros-Rudolph C.M. Weger W. Ahlgrimm-Siess V. Salmhofer W. et al.Pilot study using teledermatology to manage high-need patients with psoriasis.Arch Dermatol. 2010; 146: 200-201Crossref PubMed Scopus (37) Google Scholar screening pigmented lesions,2Kroemer S. Frühauf J. Campbell T.M. Massone C. Schwantzer G. Soyer H.P. et al.Mobile teledermatology for skin tumour screening: diagnostic accuracy of clinical and dermoscopic image tele-evaluation using cellular phones.Br J Dermatol. 2011; 164: 973-979Crossref PubMed Scopus (165) Google Scholar and may offer PCPs easier access to teleconsultations2Kroemer S. Frühauf J. Campbell T.M. Massone C. Schwantzer G. Soyer H.P. et al.Mobile teledermatology for skin tumour screening: diagnostic accuracy of clinical and dermoscopic image tele-evaluation using cellular phones.Br J Dermatol. 2011; 164: 973-979Crossref PubMed Scopus (165) Google Scholar; however, barriers to MT have not been evaluated. This pilot study assessed the feasibility of using MT in a primary care setting. We report here the PCP-reported barriers to using MT. The University of Arizona Institutional Review Board approved this study. A convenience sample of 8 PCPs in community practices with access to an iPhone 4/4S were oriented to MT and study procedures, and were given a Canfield DermScope attachment (Fairfield, NJ). In one clinic, 4 participants shared an iPhone 4 and DermScope. None of the participants had previous dermoscopy training. Participants evaluated suspect skin lesions using the Three-Point Checklist3Zalaudek I. Argenziano G. Soyer H.P. Corona R. Sera F. Blum A. et al.Three-point checklist of dermoscopy: an open internet study.Br J Dermatol. 2006; 154: 431-437Crossref PubMed Scopus (96) Google Scholar and used the DermScope to image at least 20 lesions. They completed an evaluation form for each lesion, noting the diagnosis, management choice and a brief summary of the patient’s mole count, skin type, and personal and family history of skin cancer. They also documented problems implementing MT in practice. A qualitative content analysis of e-mailed concerns about MT and survey data yielded two categories of barriers to use of this technology: Technological Barriers and Perceived Lack of Time (Table II).Table IIBarriers to mobile teledermoscopy useBarriersExamples in primary careSpecific issuesClinicalImage capture learning curve•Multiple images may need to be captured to achieve optimal image quality.•Difficulty in distinguishing between polarized and nonpolarized light settings•Difficulty obtaining focus and optimal light exposureTechnologicalApp deficiencies•If image is e-mailed before it is saved, image details are lost.•The app does not automatically number images consecutively.•It is difficult to differentiate which images have or have not been assigned to a patient profile.•The app lacks an auto-fill or field suggestion drop-down menu.Current format requires PCPs to use multiple devices for image submission (iPhone, PC, fax machine)∗Inclusion of separate PCP image evaluation forms in routine tele-dermatoscopic consultations may be specific, but not limited to, our study and varies in different clinical settings.•Images e-mailed from iPhone to teledermatologist.•PCP image evaluation form must be completed separately.•The PDF form can be filled out on a computer workstation and e-mailed to the teledermatologist or•Hard copy of form can be filled out by hand and faxed to teledermatologist.•Potential for images to be matched with wrong evaluations.•Exacerbated in a setting in which multiple providers shared an iPhone and DermScope•Partially alleviated by manual form completion and faxingMobile network/Wi-Fi access•Mobile network availability sporadic•Access to Wi-Fi requires multiple steps.•Network settings must be configured on a mobile device.•A secured network must be logged onto before e-mailing the image to the teledermatologist.Multiple users for one mobile digital device•PCPs leave images unassigned to a patient profile.•There is confusion as to which images were captured from which patient.Perceived lack of timeClinic visit•Multiple complaints must be addressed during visit; dermatologic concerns may be secondary to chief complaint.•This led to difficulty in patient recruitment.•PCP may not have the mobile teledermatoscope available and must leave the exam room to retrieve it.•Navigating the app options is time consuming.•Example: Image details must be saved prior to e-mailing the image; otherwise, all notes and details will be lost.Multiple device use•Finding the image evaluation PDF on the computer and sitting down to fill or submit the form takes too much time.∗ Inclusion of separate PCP image evaluation forms in routine tele-dermatoscopic consultations may be specific, but not limited to, our study and varies in different clinical settings. Open table in a new tab This small study begins to clarify barriers to MT application in the primary care setting. The findings reflect concerns in previous teledermoscopy studies about increased workload and complex, time-consuming teledermatology consultation systems.4Collins K. Bowns I. Walters S. General practitioners’ perceptions of asynchronous telemedicine in a randomized controlled trial of teledermatology.J Telemed Telecare. 2004; 10: 94-98Crossref PubMed Scopus (27) Google Scholar In our study, attenuation of image-submission errors when PCPs switched from a fillable PDF image evaluation to manual form suggests difficulty using new technology, specifically with older PCPs who may prefer traditional methods of lesion evaluation and referral.5Moffatt J.J. Eley D.S. Barriers to the up-take of telemedicine in Australia—a view from providers.Rural Remote Health. 2011; 11: 1581PubMed Google Scholar Although the available dermoscopic attachments have their own app (Table I), one with a more straightforward interface may decrease time spent on storing and submitting images, enabling MT use within a 15-minute visit. This app would automate image tracking, generating a PCP evaluation form for each image with identifiers unique to each pair, and thereby mitigate errors in image and evaluation pairing, particularly in settings where PCPs may share an iPhone. The small sample of PCPs precludes conclusions of whether the barriers to MT use are generalizable to MT and teledermoscopy. Despite this, the participants were from multiple practices, gender and age groups, each contributing different barriers to MT use. Finally, while MT is more accessible and convenient than clinical imaging, future MT platforms should be further assessed for barriers to use prior to implementation in a primary care setting.