Smartphone platform–based teledermatology was reliable for the initial triage of inpatient dermatology consultations in a prospective study at an academic medical center.
Teledermatology has demonstrated effectiveness in outpatient settings, but its use for inpatient settings, where dermatology consultive services may be limited or lacking, has not been well explored, wrote John S. Barbieri and his colleagues at the of the University of Pennsylvania, Philadelphia. Their findings were published online Feb. 12 in JAMA Dermatology.
In this study of 50 adult inpatients for whom a dermatology consultation was requested, an in-person dermatologist determined that 66% of consultations could have been triaged to the next day or later and that 18% could have been triaged to outpatient care after hospital discharge. Two independent teledermatologists each said 60% could be triaged to the next day or later. One said 12% could be deferred to outpatient care and the other said 8% could be deferred.
The in-person dermatologist and the teledermatologists agreed 90% of the time regarding whether the patient needed a same-day consultation. When a teledermatologist did not recommend that the patient be seen the same day, there nevertheless was complete diagnostic agreement for 60% of cases and partial diagnostic agreement for 40% of cases reported.
Furthermore, if the in-person dermatologist recommended a biopsy, the teledermatologists agreed, on average, in 95% of cases, the investigators said (JAMA Dermatol. 2014 Feb. 12 [doi:10.1001/jamadermatol.2013.9517]).
For triage, concordance between the in-person dermatologist and the teledermatologists was moderate, and inter-rater reliability between the two teledermatologists was moderate. For biopsy, concordance between the in-person dermatologist and the teledermatologists was fair to moderate, and inter-rater reliability between the two teledermatologists was substantial.
The degree of diagnostic agreement in this study was consistent with that reported in the literature, Mr. Barbieri and his associates noted.
The teledermatologists reported that they would "feel comfortable managing this patient with teledermatology alone" in 58% and 90% of cases, respectively.
"Our findings suggest that teledermatology is reliable for the initial triage of inpatient dermatologic consultation at an academic medical center. ... In addition to being reliable, teledermatology may also increase efficiency when used to triage inpatient consultations," the investigators wrote, explaining that the teledermatologists’ ability to safely triage 60% of consultations to the next day or later would create an opportunity to batch consultations together.
For an outpatient dermatologist serving as a part-time consultant for a hospital, batching consultations would optimize time spent at the hospital, they pointed out.
The teledermatologists also were able to safely triage another 10% of patients, on average, to outpatient care, eliminating the need for them to be seen in the hospital, Mr. Barbieri and his coworkers said.
The findings also suggest that some patients can be managed by teledermatology alone.
Study subjects were consenting adult patients who were hospitalized for any indication. The dermatology consultations for the patients were requested between Sept. 1, 2012, and April 31, 2013.
The patients received a standard complete inpatient consultation, which involved a same-day consultation with the in-person dermatologist. For the purposes of the study, the dermatologist recorded a triage decision based on when he believed the patient could have been seen, whether a biopsy was needed, and up to three possible diagnoses under consideration.
Additionally, a teledermatology consultation was submitted by a blinded, trained medical student using the AccessDerm smartphone platform from Vignet, and the consultation was evaluated by two independent experienced teledermatologists who recorded the same information recorded by the in-person dermatologist.
The limitations of this study included the location choice of an academic medical center, where patients may present with more complex and acute illnesses, compared with patients at a community hospital. Also, the use of standardized templates did not allow for multiple lesions to be evaluated separately. These limitations could actually be expected to increase the difficulty of the teledermatology consultations, so the findings "may represent a lower bound to the reliability of teledermatology for the triage of inpatient dermatologic consultations," the investigators noted.
Future studies should assess whether the results can be generalized to a community hospital setting, Mr. Barbieri and his associates said.
One of the study authors, Ryan Littman-Quinn, reported receiving 25% of his salary from Vignet for consultation on unrelated projects.