new ata teledermatology practice guidelines

©AmericanTelemedicineAssociation

ACKNOWLEDGEMENTSTheAmericanTelemedicineAssociation(ATA)wishestoextenditssincereappreciationtotheATATeledermatologyGuidelinesWorkGroupandtheATAPracticeGuidelinesCommitteeforthedevelopmentoftheseguidelines.Theirhardwork,diligenceandperseverancearehighlyappreciated.

TELEDERMATOLOGYPRACTICEGUIDELINESWORKSGROUP

•Leadership•Chair:KarenMcKoy,MD,MPH,DepartmentofDermatology,LaheyHospital&MedicalCenter,AssistantClinicalProfessor,HarvardMedicalSchool

•WorkGroupMembers(AlphabeticalOrder)•NinaMAntoniotti,RN,MBA,PhD,ExecutiveDirectorofTelehealthandClinicalOutreach,SIUSchoolofMedicineAprilArmstrong,MD,AssociateDeanforClinicalResearch,DirectorofClinicalResearch,SouthernCaliforniaClinicalandTranslationalScienceInstitute(SCCTSI)ViceChair|Director,ClinicalTrialsandOutcomesResearch|Director,PsoriasisProgramDepartmentofDermatologyKeckSchoolofMedicineUniversityofSouthernCalifornia

DanielBernstein,MD,DermatologyResident,TheMountSinaiHospital

AnneBurdick,MD,MPH,AssociateDeanforTelemedicineandClinicalOutreach,ProfessorofDermatology,Director,LeprosyProgram,UniversityofMiamiMillerSchoolofMedicineKarenEdison,MD,Professor&Chair,DepartmentofDermatology;MedicalDirector,MissouriTelehealthNetwork;Director,CenterforHealthPolicy,UniversityofMissouriSchoolofMedicineMarkGoldyne,MD,Professor,DepartmentofDermatology,UniversityofCaliforniaSanFranciscoCarrieKovarik,MD,AssociateProfessorofDermatology,UniversityofPennsylvaniaJosephKvedar,MD,VicePresidentConnectedHealth,PartnersHealthCareJimLarkey,MBA,CanfieldScientific


IvyLee-Keltner,MD,AssistantClinicalProfessor,DepartmentofDermatology,UniversityofCaliforniaSanFranciscoJulesLipoff,MD,AssistantProfessorofDermatology,UniversityofPennsylvania*DennisOh,MD,AssistantProfessorinResidence,DepartmentofDermatology,UniversityofCaliforniaSanFranciscoHonPak,MD,AssistantProfessor,DepartmentofDermatology,TheGeorgeWashingtonUniversityMarkP.Seraly,MD,ClinicalAssistantProfessorofDermatology,UniversityofPittsburghDanielSiegel,MD,StateUniversityofNewYorkHealthSciencesCenteratBrooklynTejasviTrilokraj,MD,AssistantProfessor,DepartmentofDermatology,DirectorofTeledermatology,UniversityofMichigan*JohnWhited,MD,ResearchandDevelopment,DurhamVAMedicalCenter,AssociateProfessor,DepartmentofMedicine,DukeUniversitySchoolofMedicine*ThecontentoftheseguidelinesweredevelopedbytheauthorsandadoptedbytheATA.TheydonotnecessarilyreflectthepositionorviewsoftheUnitedStatesrDepartmentofVeteransAffairs.

•ATAPracticeGuidelinesCommittee•Chair:ElizabethA.Krupinski,PhD,Professor&ViceChairforResearch,DepartmentofRadiology&ImagingSciences,EmoryUniversity

•CommitteeMembers•NinaAntoniotti,RN,MBA,PhD,ExecutiveDirectorofTelehealthandClinicalOutreach,SIUSchoolofMedicineDavidBrennan,MSBE,Director,TelehealthInitiatives,MedStarHealthAnneBurdick,MD,MPH,AssociateDeanforTelemedicineandClinicalOutreach,ProfessorofDermatology,Director,LeprosyProgram,UniversityofMiamiMillerSchoolofMedicineJerryCavallerano,PhD,OD,StaffOptometrist,AssistanttotheDirector,JoslinDiabetesCenter,BeethamEyeInstituteHelenK.Li,MD,AdjunctAssociateProfessor,UniversityofTexasHealthScienceCenterLouTheurer,GrantAdministrator,BurnTelemedicineProgram,UniversityofUtahHealthSciencesCenter


JillM.Winters,PhD,RN,PresidentandDean,ColumbiaCollegeofNursing

•ContributingEditor•RashidBashshur,PhD,SeniorAdvisorforeHealth,UniversityofMichiganHealthSystem

•ATAStaff•JordanaBernard,MBA,ChiefProgramOfficerJonathanD.Linkous,CEO


PRACTICEGUIDELINESFORTELEDERMATOLOGY

TABLEOFCONTENTS

PREAMBLE 1

SCOPE 2

INTRODUCTION 2

PRACTICEGUIDELINES 3

ClinicalPracticeGuidelines 3

I. PreliminaryConsideration 4 A. Patient-ProviderRelationship 4B. InformedConsent 4C. PhysicalEnvironment 4

II. TelemedicineManagementofthePatient 5A. PatientEvaluationandExamination 5B. Follow-upandCareCoordination 6C. Documentation 6

III. Quality 6IV. EthicalConsiderations 7V. Direct-to-PatientCare 7

TechnicalGuidelines 7

I. CommunicationModesandApplications 7II. DevicesandEquipment 8III. ImageQuality 8IV. ImageDisplay 11V. Connectivity 11VI. Privacy 12

AdministrativeGuidelines 12

I. Security 12II. Privacy 13III. LicensingandCredentialing 13IV. Liability 13

APPENDIX 14

Definitions

References 15

©AmericanTelemedicineAssociation|Page1

PREAMBLETheAmericanTelemedicineAssociation(ATA)bringstogetherdiversegroupsfromtraditionalmedicine,academia,technologyandtelecommunicationscompanies,eHealth,alliedprofessionalandnursingassociations,medicalassociations,government,military,regulatoryandotherstoaddressandadvancecompliancewithlegal,ethical,andprofessionalstandardsinthepracticeoftelemedicine.ATAhasembarkedonanorganizedefforttoestablishguidelinesforthepracticeoftelemedicineinvariousclinicalapplicationstoassureuniformqualityofserviceforpatientsandproviders,toenhancepatientexperience,andtoenableproviderstodeliverappropriatecare.Theguidelinesaredevelopedbypanelsthatincludeexpertsfromthefieldandotherstrategicstakeholders,andaredesignedtoserveasastandardreferenceandeducationaltoolforprofessionalstoprovideappropriatecareforpatients.Theprocessfordevelopingtheseguidelinesisbasedonprofessionalconsensusandarigorousreviewincludingopenpubliccommentaryperiod,withfinalapprovalbytheATABoardofDirectors.Guidelinesarereviewedandupdatedperiodically.Thepurposeoftheseguidelinesistoassistprovidersinpursuingasoundcourseofactioninprovidingeffectiveandsafemedicalcarethatisfoundedoncurrentscientificknowledge,technologicalrequirements,andpatientneeds.Safeandeffectivepracticerequirestechnicaltraining,professionalknowledgeandskill,andexplicitprocesses,asdescribedineachdocument.AllguidelinesissuedbytheATAarepropertiesoftheATA.AnymodificationorreproductionofthepublishedguidelinemustreceivepriorapprovalbytheATA.Compliancewiththeseguidelinesalonewillnotguaranteeaccuratediagnoses,appropriateclinicaltreatmentoroptimaloutcomes.Adivergencefromtheguidelinesmaybeindicatedundercertainconditions,suchasemergencysituationsinplaceswithlimitedresourcesthatcallforpromptactiontoattendtothepatient.Similarly,technologicaladvancesmayalterprevailingpracticesorprovidenewandexpandedopportunities.Thetechnicalandadministrativeguidelinesinthisdocumentdonotpurporttoestablishbindinglegalstandardsfordeliveringtelemedicineservices.TheyarebasedontheaccumulatedknowledgeandexperienceoftheATAworkgroupsandotherprofessionals.

• ThepreviousATATeledermatologyPracticeGuidelineswereissuedin2007.Thisistherevisedversionreflectingnewknowledgeinthefield,newtechnologies,andtheneedtoincorporateteledermatologypracticeinavarietyofsettingsincludinghospitals,urgentcarecenters,FederallyQualifiedHealthCenters,school-basedclinics,publichealthfacilitiesandpatienthomes.


SCOPETheteledermatologyguidelinesapplytoindividualproviders,groupandspecialtypractices,hospitalsandhealthcaresystemswhenprovidingservicesviainformationandcommunicationtechnology(ICT)asasubstitutefororanadjuncttoin-personcare.Theusersoftheseguidelinesareurgedtoreviewandcomplywithprofessionalguidelineswithintheirdomainofpracticeastheypertaintoprevention,diagnosis,treatment,andfollow-upofskindisorders.TheseguidelinespertainprimarilytohealthcareprovidersandpatientslocatedintheUnitedStates(U.S).WheneitherorbothpartiesarenotwithinthejurisdictionoftheU.Sapplicablelocalguidelinesandprotocolstakeprecedenceaccordingtotherulesofprevailingjurisdictions.[1,2]Theguidelinesaddressthreeaspectsofservicedelivery:clinical,technicalandadministrative.Undereachset,theguidelinesareclassifiedaccordingtofourlevelsofadherence,showninboldthroughoutthedocument:

• “Shall,”indicatesrequiredactionoradherencewheneverfeasibleand/orpractical.• “Shallnot”indicatesaproscriptionoractionthatisstronglyadvisedagainst.• “Should”indicatesarecommendedactionwithoutexcludingothers.• “May”indicatespertinentactionsthatmaybeconsideredtooptimizethetelemedicine

encounter.

INTRODUCTION

Thepracticeofdermatologyisparticularlysuitedtotelemedicinebecauseskindisordersarevisibletothehumaneye,andclinicalinformationcanbeacquired,stored,andtransmittedforaccuratediagnosisandappropriatetreatmentinthemajorityofcases.Casesthatrequirebiopsycanalsobeidentifiedandappropriatereferralinitiatedpromptly.Thepracticeofteledermatologycanalleviatethemaldistributionofspecialtycare,andenablepatientsnotlocatedingeographicproximityofexpertresourcetoreceivecare.Thefollowingguidelinesaredesignedtoestablishcoherent,effective,safeandsustainablestandardsforthepracticeofteledermatology.TheGuidelinescoverthreeareas,reflectingtheprocessesassociatedwithmostteledermatologyconsultations:ClinicalPractice,TechnicalRequirements,andAdministration.TheymaybeusetogetherwiththeCoreOperationalGuidelinesforTelemedicineServicesInvolvingProvider-PatientInteractions,andATAPracticeGuidelines(3,4)forLiveOnDemandPrimaryandUrgentCare(2014).Theseguidelinespertaintothethreemodestypicallyusedforteledermatology:store-and-forward(S&F)ortransmittingdigitalimagesandassociatedpatientdatatothespecialistforconsultationatalatertime;real-timevideoteleconferencing(VTC)inwhichprovidersandpatientsinteractvialivevideoconferencing;andhybrid(utilizingbothS&FandVTC).


Thereisagrowingbodyofevidenceregardingtheeffectivenessofsynchronousandasynchronousteledermatologyforavarietyofskindisordersthatpresentindiversepracticesettingsincludingemergencydepartments,hospitals,patienthomes,schools,chroniccarefacilities,theworkplace,andthemilitary.Teledermatologyhasbeenfoundtobereliableforaccuratediagnosisandtreatmentplansforskindisorders.(5-41).Withsomeexceptions,thepreponderanceoftheevidenceconfirmsthediagnosticaccuracyofteledermatologycomparedtoin-personencounters(9,13,21,28,29,41-48);asare,management/treatmentrecommendations(6,11-13,15,21-23,25,26,28-31,33,37,43,45,46-53)Clinicaloutcomesandqualityoflifemeasuresaresimilaraswellfortelemedicineandin-personcare.(54-59)(60-64)Moreover,patients,referringclinicians,anddermatologistshaveexpressedhighlevelsofsatisfactionwithteledermatology,(15,23,33,34,38,65-80)asitfacilitatesaccesstodermatologicexpertiseforpatientswhoaregeographicallyorlogisticallychallenged.

PRACTICEGUIDELINES

Inteledermatology,store-and-forward(S&F)communicationtypicallyreferstothesendingorforwardingofdigitalimagesandassociatedpatientdatatothespecialistforstorageandconsultationatalatertime.Forreal-timevideoteleconferencing(VTC),providersandpatientsinteractvialivevideoconferencing.TheserecommendationsapplytoS&F,VTCandhybrid(utilizingbothS&FandVTC)modesforteledermatology.

CLINICALPRACTICEGUIDELINES

Manyskinconditionslendthemselvestoatelemedicineconsultasdefinedinthisdocument.Typically,theseincludeconditionsforwhichthereisreasonablecertaintyofestablishingadiagnosisandgeneratingatreatmentplanonthebasisofvisualinformationandaccesstoamedicalrecord.Theultimatedecisionforateledermatologyconsultismadebythepatient,thereferringproviderandtheteledermatologist.Theseguidelinesdefineappropriateconditionsandparametersforthesafeandeffectivepracticeoftelemedicineoncurrentevidence.Theyarenotintendedtosubstituteforindependentmedicaljudgmentsthatpertaintoindividualcircumstances.

Bothreferringprovidersandconsultants(hereafterreferredtoasproviders)shallexercisetheirprofessionaljudgmentregardingtheappropriatenessoftelemedicineonacasebycasebasis,takingintoaccountthepresentingcondition,theirabilitytomakeadefinitivediagnosis,andtheircomfortandexpertise.ProvidersshallobserverelevantpracticeguidelinesandpositionstatementsdevelopedbytheAmericanAcademyofDermatologyandotherrelatedprofessionalorganizations.


I.PRELIMINARYCONSIDERATIONS

A.Patient-ProviderRelationshipProvidersshallconformtoallapplicablestateandfederalregulationsthatpertaintothepracticeofmedicine,includingtheestablishmentofaprovider-patientrelationshipandtheappropriateconditionsformakingdiagnosticandtreatmentdecisions-includingprescribing.Ifthepatientdoesnothaveaprimarycareprovider,theconsultingprovidershouldrecommendappropriateoptionstoassurecontinuityofcare.Practiceorganizationsshouldestablishstandardoperatingproceduresandworkflowsfortelemedicineconsultsconsistentwithprevailingrulesandnorms.

B.InformedConsentPriortotheinitiationofatelemedicineencounter,theproviderordesigneeshallsecurepatientconsenttobetreated,asrequiredbylocalorstateregulations.Thiscanbedoneinwritingorverbally,anditshouldincludeanexplanationofthebenefitsandrisksoftelemedicineencounters.Thelanguageshallbesimpleandunderstandablebytheaveragepatient.Thisexplanationshallinclude:

• Thenatureofthetelemedicineencounter,includinganytechnicallimitationsorpotentialfordisruptionandcontingencyplans

• Proceduresforcoordinationofcarewithotherprofessionals,asindicated• Protectionofpatientidentifiableinformation• Credentialsofthedistantsiteteledermatologists• Explicitemergencyplanforpatientsinsettingswithoutaccesstoclinicalstaff• Conditionsunderwhichtelemedicineservicesmaybeterminatedandareferral

madetoin-personcare• Billingarrangements,ifappropriate

C.PhysicalEnvironment

Theprovidershalldeterminethelevelofdistraction(e.g.,noise),infringementonprivacy,andotherenvironmentalconditionsthatmayaffectthequalityoftheencounter.Inlive-interactiveencounters,thefollowingconditionsshallbeobserved:

• Bothpatientandproviderroom/environmentshallensurevisualandauditoryprivacy.

• Allpersonsintheexaminationroomatbothsitesshallbeidentifiedpriortotheconsultation;anditshallbeverifiedthatallarevisibleandcanbeheard.

• Seatingandlightingshouldbedesignedforbothcomfortandprofessionalinteraction.Backgroundlightfromwindowsorothersourcesshouldbeminimized.

• Camerasshouldbeplacedonasecure,stableplatformtoavoidunnecessarymovementduringthevideoconferencingsession,andshouldbeplacedatthesameelevationastheeyeswiththefaceclearlyvisibletotheotherperson.


II.TelemedicineManagementofthePatientProvidersshalldeterminetheappropriatenessoftelemedicineonacase-by-casebasis,andwhetherthepatientmustbeseeninpersonandforwhatpurpose.Thisinformationshallbedocumentedinthepatient’srecordconsistentwithrelevantstandardsinevaluatingthepatient.

A.PatientEvaluationandExaminationTheprovidershallobtainthedatanecessaryformakingadiagnosis,differentialdiagnosis,work-upifappropriate,andtreatmentplan,including:

• Identifyinginformation(e.g.,age,gender,race)• Chiefcomplaint(s)• Historyofpresentillness(includinglocation,description,size,quality,severity,

duration,timingandcontextmodifyingfactorssuchaspriortreatmentsandresponsestotreatments)

• Associatedsignsandsymptoms• Pastmedicalhistory,ifpertinent• Familyhistory,ifpertinent• Medications• Allergiesincludingnature,severityofreaction,andtreatment• Adequatediagnosticqualityimages,asavailable

Diagnosticdata(e.g.,obtainedviaself-reportoraccesstodatabases)andlaboratorytestresults

SpecialConsiderations:Thereferringandconsultingprovidersshalldecidewhethertoexcludecertaintypesofcasesthatrequirespecialconsideration:

o Fullbodyexamination:Afullbodyskinscanusingvideoconferencing(VTC)orstore-and-forward(S&F)isfeasible,butitmaynotshowallskinlesionsandsurfaceswithsufficientdetail.Enhancedlighting,multipleimagingandseveralanglesmaybehelpful.

o Hair-bearingskin:Thescalpandotherareaswithasignificantamountofhairmayneedtohavehairphysicallydisplacedorremoved,andspeciallightingmayenhanceviewingconditions.

o Pigmentedlesions:Pigmentedlesionsmaypresentadiagnosticchallengeandshouldrequireahigherindexofsuspicionwheninterpreting.Peripheraldevicessuchasdermatoscopesandconfocalmicroscopymaybeincorporatedintoteledermatologyconsultations(1,27,50,74,82,93,131).

o Mucosallesions:Mucosallesionsandorifices,includinggenitalia,oftenrequirespecialattentiontolightingandexposureinordertoallowexamination.

o Skincolor:Lightingandbackgroundconditionsmaychangethecolorofskinlesioncapturedinimages.


B.Follow-upandCareCoordinationContinuityofcareisacriticalelementinqualityofmedicalcareandpatientwell-being.Hence,teledermatologistsshouldmakeeveryattempttoidentifythepatient’susualproviderandlocalmedicalresourcestocoordinatecareandmakereferralsasindicated.Theteledermatologistshallcommunicateresultsoftheencountertothepatient’sreferringproviderand/ortothepatient,usingsecureelectronicmethodsinadditiontoverbalcommunicationinlive-interactiveencounters.Afollow-upplanaftertheencountershallbedevelopedandcommunicatedwiththepatientand/orthereferringprovider.Thisincludesanyrequiredfollowup,referrals,aswellasclinicalsignsthatsignifyasignificantexacerbation.Laboratoryandotherdiagnosticsorderedshallbefollowedupinatimelymannerwiththepatientandtheirproviders,asindicatedandnecessary.

C.DocumentationEachpatientencountershallbedocumentedandmaintainedinasecure,HIPAA(HealthInsurancePortabilityandAccountabilityAct)compliantformandlocation.Documentationshallincludeataminimumthediagnosisand/ordifferentialdiagnosisandrecommendedmanagement/treatmentplanandshallincludeasummaryofthefindings.Documentationshalladheretoallmedical-legalstandardsofcare,and,ifappropriate,insurancerequirementsforfuturereviewandaudit.Providersshallmaintainuptodatebusinessassociateagreementswithtechnologysuppliersandothervendorswhohaveaccesstopatient’spersonalhealthinformationLanguageusedtodocumenttheencountermayinclude:“Basedontheimagesandhistoryprovided,myimpressionisasfollows.”

Recordingoflive-interactiveencountersisoptional,unlessitisrequiredinparticularsettings.Patientconsentisnecessarywhentherecodingismadeforqualityassurance,trainingorresearchpurposes.Awrittenrecordoftheconsultshallbekeptatleastatonesite(referringproviderorconsultant).Instore-and-forwardencounters,electronic,faxed,mailedore-mailednotesshallbecomepartofthepatient’smedicalrecord,includinganyteledermatologistannotations.

Thereferringproviderandteledermatologistshouldestablishanexplicitprocessforpatientstorequestcopiesoftheirtelemedicineencounters.

III.QualityProvidersshallemployacontinuousqualityimprovementprogram,includingaclinicaloversightprocess.Thequalityimprovementprogramincludes:


• technicaloradministrativefailures• appropriatenessofvirtualencounter• patientand/orprovidersatisfaction• patientoutcomes• pathologyorimagingresults• recommendationsforfollow-up

IV.EthicalConsiderationsTelemedicinepracticeshallconformtothesameprofessionalethicsthatgovernin-personcare.Telemedicineprovidersshallincorporateethicalstatementsandpoliciesandlegal/regulatoryrequirementsintotheirstandardoperatingprocedures,including:

• Anexplicitcodeofethics.• Compliancewithfederal,state,andjurisdictionallawsandregulations,and

institutionalpolicies.• Non-discriminationclauseregardingdenialofservicetoindividualsonthebasisof

location,socio-economicstatus,diseaseordisability,gender,genderpreferenceorsexualorientation,ethnicity,nationaloriginorreligiousaffiliation.

• Provisionofserviceshouldnotbeconditionaluponreceiptofpaymentbythepatient

V.Direct-to-PatientCareBasedonthelimiteddataavailablefromtheemergingpracticeofdirect-to-patientteledermatologyandsomepotentialconcernsregardingquality,third-partybenefits,follow-up,anddisclosures,anyonepracticingdirect-to-patientteledermatologyshalldevelopandimplementanexplicitqualityassuranceplanandproperdisclosures.ThedisclosurecanbepostedonaWebsite,softwareapplicationorotherinformationsource,andshouldincludebasicinformationonprofessionalqualifications,credentialingandprivileging;thenatureoftheserviceprovided(suchasconsultations,referralsandfollow-up);participationinnetworksorhealthsystems;andpatient-relevantinformationsuchasqualityassurancemechanisminplaceandpatientaccesstotheirrecords.

TECHNICALGUIDELINES

I.CommunicationModesandApplicationsAlleffortsshallbetakentouseappropriateICTmodalitieswithauthentication,verification,confidentiality,andsecurityarrangementsandwithfullcompliancewithHIPAAlaws.Softwareplatformsshouldnotbeusedwhentheyincorporatesocialmedia.


II.DevicesandEquipment

Devicesshallhaveup-to-dateantivirussoftwareandasystem-widefirewallwithsecuritypatchesandupdatesontheoperatingsystemandthirdpartyapplications.Providers/organizationsshallusedevicemanagementsoftwaretoprovideconsistentoversightofapplications,devicesanddataconfigurationsandsecurity.Organizationsandprovidersshallensurethatequipmentandconnectivityarefunctioningproperlywithregulartestingandmaintenance.

III.ImageQuality

Imagequalityisessentialforprovidingteledermatologyservice.Thisappliestobothsynchronousandasynchronousencounters.Thefollowingtechnicalspecificationsshallbeobserved:

A.RequirementsforReal-timeVideoconferencing(synchronousencounters)

Thetechnologyshallmeetthefollowingspecifications:

• H.264videocompressionstandardorhigher• H.323compliant• H.261videocompressionstandardcompatibility• G.711audiocompressionstandardorhigher• Livevideoresolution4CIF(704x480)orhigher• ContentresolutionXGA(1024x768)orhigher• Capabilityofconnectingat384kbpsrunning4CIF@30fps• Minimumof384kbpsconnectionspeedbetweenreferralandconsultantsites• Differenttechnologiesmayrenderdifferentvideoqualityatthesamebandwidth;

henceeachendpointshallusebandwidthsufficienttoachieveclinicalquality.• Wherepractical,providersmayrecommendpreferredvideoconferencingsoftware

and/orvideoandaudiohardwaretothepatient,aswellasprovidinganyrelevantsoftwareand/orhardwareconfigurationconsiderations.

• Theprovidersandpatientsmayuselinkbandwidthtesttoolstodetermineconnectivitybeforestartingthesessiontoensuresufficientqualityofservice.

• WiredlinksprovidethemostreliableconnectivityontheInternet,andtheyshouldbeusedwhenavailable.

• Thevideoconferencesoftwareshouldadapttochangingbandwidthavailabilitywithoutlosingtheconnection.Iffeasible,redundantsystemsshouldbeinplace.

LightingBackgroundlightingshouldbeminimized,andadditionalindoorlightingusingfluorescentdaylightorfullspectrumbulbsmaybeneededtoaugmenttheilluminationdeviceontheexaminationcameras.


ViewsTheimagershouldholdthecameraatadistancetoshowthegeneraldistributionoftheskinlesion(s)beforeobtainingclose-upimages(usuallyabout24”formostbodyareas).Whenmovingthecameratoshowthedistributionandotherdetails,theimagershouldrequestfeedbackregardingthespeedofcameramovementfromthedermatologisttoensureadequateimagequality.Obliqueviewsmaybeincludedtoshowskinsurfacechanges.PositioningIfthecameradoesnotcontainanimageviewer,itisimportanttopositionthepatient(asfeasible)inbetweenthecameraandthevideoconferencemonitorinonelineofsight.VerbalizationofBodyRegionsBeingExaminedTheimagershallidentifythepartofthebodybeingimaged,notingimportantcharacteristicssuchassize,color,andappearanceofskin.

FocusCameraanglemustbeperpendiculartotheskinforclose-upimages,notingthedistancetotheskinlesion(s),andthecameramustbeheldasstillaspossible.

Freeze-frameCaptureMostvideocamerasareequippedwithafreeze-framefeature,whichisusefulfordiagnosis,especiallywhenbandwidth(connectivityspeed)islow.Freeze-framesallowthedermatologisttoappreciatefinefeaturesofskinlesionsandminimizeimagedegradationthatoccurswhenscanningwiththecamera.

ColorViewingdevicesmaybecolorcalibrated.AMacBethcolorchartmaybeuseful.

OtherAvoiddistractingjewelryandclothing.Usemeasurementtoolstoshowsizeanddistribution,appropriate.

B.RequirementsforAsynchronousImaging

DigitalCamerasDigitalcamerasshallbeusedforimageacquisition,withaminimalresolutionof1024x768pixels(0.8megapixel),preferably3264x2448pixels(8-megapixel)orgreaterMacromodeMacromodecapabilityisideal(close-upmodeor“flower”image).BackgroundUseasolid,neutralcolorwithanon-reflectivesurfaceLighting


Diffuse,indirectlightisoptimal,usingfluorescentdaylightorfullspectrumbulbs(avoidincandescent).Ifoutdoorsusewell-litareas,orevenlyshadedareasifsunny.FlashUseflashtohelpeliminateshadows,butitmaycausewhiteoutiftooclose.CompressionUseJPEGmediumorlowsetting(nomorethan20:1).FocusAdjustcameraandpatienttohavecameraangleperpendiculartotheskinlesionsbeingimaged.Useautofocuswithareaofinterestincenterofframe.Ifnotpossible,focusfirstontheareaofinterest,depressshutterbuttonhalf-waytofocus,andthenmovethecameratocentertheimagebeforefullydepressingshutterbutton.ColorViewingdevicesmaybecolorcalibrated.MacBethcolorchartmaybeuseful.WhiteBalanceTheimagingdeviceshallbecalibratedforwhitebalancebytakingapictureofwhiteorgraycard.Theimagecanbeusedtosetthewhitebalancebyaccessingcustomwhitebalance(typicallyavailableundercamerasettings).Thewhitebalancecalibrationshouldberecalibratedifthereisachangeinthephysicallocationoftheimagingdeviceorlightingintheroom.ViewsAchaperoneorlegalguardianshouldbeusedasrequiredorappropriate.

Ifmorethanoneareaisinvolved,allregionsinvolvedshouldbeincluded.Takeimagestoshowlocationandarrangementoflesion(s).Takeseveralviews.• Far-entirebodyorobviousregion• Medium–includeananatomicallandmarksuchasthenavelorhand• Close-Up-ifthecamerahasamacrocapacity(the“flower”image)animagecanbe

takenwithin18inchesfromtheskin;otherwiseusetheopticalzoom,ifavailableforaclose-up.Useperpendicularandobliqueviewsforclose-up.

Complementaryviewsshouldbeincluded.Forexample,ifthehandsareinvolved,takephotosofthefeet,kneesandelbows(additionalexampleslocatedintheATAQuickGuidetoStore-and-ForwardTeledermatologyforReferringProviders)(SeeAppendix)Peripheraldevicessuchasdermatoscopesandconfocalmicroscopymaybeincorporatedintoteledermatologyconsultations.Imagesshouldbeobtainedusingahybridorpolarizeddermatoscope.Dermoscopyimagesmaybetakenwithadermatoscopelessthan2inchesfromtheskin(non-contactmode)andtouchingtheskinaftercleaningtheinstrumentandskinwithalcoholpads(contactmode)toimproveluminance.


Distractingjewelryandclothingshouldberemovedpriortoimaging.Lesionsshouldbeidentified.Identificationmarkersshouldbeplacedadjacenttothelesionwithoutcoveringanyportionofit.Ontheskin:Lesionscanbeidentifiedusingadhesivelabels,surgicaltape,washablemarkersorotherremovabletools.Beforesendingtheimage,theusershouldaddadigitalcircle,boxorarrowtotheimage.Arulershouldbeincludedineachimage(generalandclose-up)incloseproximitytothelesionsothatsize/extentcanbedeterminedfromtheimage.Imagesshallnotbealteredinanywayaftertaken.Images,transmittedtextandteledermatologistresponseshallbecomepartofasecure,retrievablemedicalrecord.Imagesshouldbereviewedduringtheacquisitionprocesstoensureacceptablequality.Sendonlyhelpfulandclearimagestotheconsultant.

C.MobileDeviceUse

DeviceCameraAllimageacquisitiondetailsdescribedabovefordigitalcamerasapplytomobiledevicecameras.

Applications/Software

Applications(apps)shallallowforimagesandmedicalinformationtobeuploadedinasecure,HIPAAcompliantandencryptedprotocol,suchastheAdvancedEncryptionStandard(AES),accessibleonlybysecureregistrationandpassword;mayincludeaprotocolforreimbursement,anddownloadabletoanelectronicpatientrecord.

IV.ImageDisplay

Monitorsforviewingimagesshallhaveaminimumof1024x768pixelresolution,minimumcontrastratioof500:1,minimumluminanceof250cd/m2andminimumdotpitchof0.19.Adedicatedmonitororsetofmonitorsmaybeused.Colorcalibrationmaybeusedtoensurethereliablecolorrendition.

V.Connectivity


VI.PrivacyAllpatientidentifiableinformation(protectedhealthinformation)shallbetreatedasconfidentialandprotectedfromunauthorizeduseandshallmeetrecognizedstandards.Individualsinchargeoftechnologyshallfamiliarizethemselveswiththetechnologiesavailableregardingcomputerandmobiledevicesecurity.Whenusingamobiledevice,specialattentionshallbeplacedontheprivacyofinformationbeingcommunicatedorstored.Devicesshallbeconfiguredtoutilizeaninactivitytimeoutfunctionthatrequiresapasswordorre-authenticationtoregainaccess.Thistimeoutshouldnotexceed15-20minutes.Mobiledeviceswithpatientinformationshouldbekeptinthepossessionoftheproviderwhentravelingorinanuncontrolledenvironment.Providersshouldhavethecapabilitytoremotelydisableordeletestoredinformationontheirmobiledeviceiflostorstolen.Patientsshouldbeinformedthatsomesoftwareandmobileappsdesignedforpatientuseseparatelyandpermanentlystoreorcreatecopiesofimagesonequipmentordevice,creatingapossiblesecurity/privacyrisk.Accesstovideoconferencingsessionsshallbelimitedtoauthorizedusers.Wholediskencryption(FIPS140-2,knownastheFederalInformationProcessingStandard,shallbeusedwhenstoringprotectedhealthinformationontheharddriveoftheproviders’computers.Patientsshouldbeinformedregardingthebestwaystoprotecttheirdevicesanddata,especiallywhenusingsoftware,web-basedormobileappsontheirown.Providersandpatientsshalldiscussanyintentiontorecordencountersorimages,thepurposeoruseoftherecording,howtheinformationwillbestored,andhowprivacywillbeprotected.Recordingsshallbeencryptedformaximumsecurity.Accesstotherecordingsshallbelimitedstrictlytoauthorizedusers.

ADMINISTRATIONGUIDELINES

I.SecurityTeledermatologistsshallkeeparecordofallusersofelectronicrecordstoassurethatonlythosewithlegitimateclinicalneedcanhavesuchaccessasstipulatedbylaw.Useofsuchrecordsforadministrative,researchorteachingshallbedefinedandapprovedbyappropriatebodies,suchasInstitutionalReviewBoards.Systemadministratorsshall:Keepdatabasefilesinencryptedformatrestandintransit.


• HavethevendorpassasecurityauditandsignaBusinessAssociateAgreementifdata

storageiscloud-based,

II.Privacy

III.LicensingandCredentialing

Providersshallfollowfederal,stateandlocalregulatoryandlicensurerequirementsrelatedtotheirscopeofpractice,andshallabidebystateboardandspecialtytrainingrequirements.Aprovidershallensurethathe/sheisdulylicensedandcredentialedinajurisdictioninwhichthepatientisphysicallylocated.Providersshallpracticewithinthescopeoftheirlicensureandshallobserveallapplicablestateandfederallegalandregulatoryrequirementsregulationsrelatedtotheuseoftelemedicine.Thepracticeofmedicineshallbedefinedasoccurringwherethepatientislocatedatthetimeofthephysician-patientencounter.Assuch,theprovidershallbeunderthejurisdictionofthestatemedicalboardwherethepatientislocated.Providerswhowishtobelicensedinmultiplestates,or“interstatemedicallicensure”shallbeawareofregulationsandoptions.Forexample,theFederationofStateMedicalBoards(FSMB)hasdraftedthe“InterstateMedicalLicensureCompact”toprovideanexpeditedlicensureprocessforeligiblephysicians.Thecompactisexpectedtoeasetheprocessofgaininglicensureinmultiplestates.AccordingtotheCompact,eligiblephysiciandesignatesthestateofprincipallicensureandselectstheothermemberstateswhereamedicallicenseisdesired.Thestateofprincipallicensurewouldverifythephysician’seligibilityandprovidecredentialinformationtotheInterstateCommission,whichcollectsanyapplicablefeesandtransmitthephysician’sinformationandlicensurefeestotheadditionalstates.Subsequently,thephysicianwouldbegrantedalicense.TheCompactdoesnotchangethestate’sexistingdefinitionofaphysicianwithinitsMedicalPracticeActnortherequirementsforstatemedicallicensure.TheenactmentoftheCompactinadditionalstatesisadynamicprocess,andthepractitionersshouldrefertowww.licenseportability.orgforthelatestupdates.

IV.LiabilityTeledermatologistsshallbecognizantoftheliabilitythatisincurredinmedicalpractice,whetherin-personorviaelectronicmeans.Providersshouldverifythattheirmedicalliabilityinsurancepolicycoverstelemedicineservices,includingservicesprovidedacrossstatelines,ifapplicable.


APPENDIX

DEFINITIONSTeledermatologyreferstothedeliveryofdermatologyspecialtyservices(advice,diagnosis,treatmentplanning,andeducation)topatientsandotherhealthcareprovidersremotelyusinginformationandcommunicationtechnology.Synchronousteledermatologyreferstotheremoteprovisionofservicesonlineorwithbothproviderandpatientcommunicatingatthesametime.Asynchronous(orstore-and-forward)teledermatologyreferstotheremoteprovisionofserviceatdifferenttimes.Hybridteledermatologyreferstoutilizingbothstore-and-forwardandvideoconferencingmodesforteledermatology.


REFERENCES 1. HogenbirkJC,BrockwayP,FinleyJ,JennettP,YeoM,Parker-TaillonD,PongRW,Szpilfogel

C,ReidD,McDonald-RenczS,CradduckT.FrameworkforCanadiantelehealthguidelines:summaryoftheenvironmentalscan.JTelemedTelecare2006;12:64-70.

2. TelehealthServiceCodeofPracticeforEurope.http://www.telehealthcode.eu/.Last

accessedDecember22,2015.3. AmericanTelemedicineAssociation’TelemedicinePracticeGuidelines.

http://www.americantelemed.org/resources/telemedicine-practice-guidelines/telemedicine-practice-guidelines#.VcJt--ezMdIlastaccessedDecember222015.

4. KrupinskiEA,BernardJ.StandardsandGuidelinesinTelemedicineandTelehealth.

Healthcare2014;2:74-93.5. KvedarJC,EdwardsRA,MennER,MofidM,GonzalezE,DoverJ,etal.Thesubstitutionof

digitalimagesfordermatologicphysicalexamination.ArchDermatol1997;133:161-167.6. ZelicksonBD,HomanL.Teledermatologyinthenursinghome.ArchDermatol

1997;133:171-174.7. LyonCC,HarrisonPV.Aportabledigitalimagingsystemindermatology:diagnosticand

educationalapplications.JTelemedTelecare1997;3(S1):81-83.8. HighWA,HoustonMS,CalobrisiSD,DrageLA,McEvoyMT.Assessmentoftheaccuracyof

low-coststore-and-forwardteledermatologyconsultation.JAmAcadDermatol2000;42:776-783.

9. WhitedJD,HallRP,SimelDL,FoyME,StechuchakKS,DruggeRJetal.Reliabilityand

accuracyofdermatologists’clinic-basedanddigitalimageconsultations.JAmAcadDermatol1999;41:693-702.

10.TaylorP,GoldsmithP,MurrayK,HarrisD,BarkleyA.Evaluatingatelemedicinesystemto

assistinthemanagementofteledermatologyreferrals.BrJDermatol2001;144:328-333.11.LimAC,EgertonIB,SeeA,ShumackSP.Accuracyandreliabilityofstore-and-forward

teledermatology:preliminaryresultsfromtheSt.GeorgeTeledermatologyProject.AustralasJDermatol2001;42:247-251.

12.MahendranR,GoodfieldMJD,Sheehan-DareRA.Anevaluationoftheroleofastore-and-

forwardteledermatologysysteminskincancerdiagnosisandmanagement.ClinExpDermatol2005;30:209-214.

13.OakleyAMM,ReevesF,BennettJ,HolmesSH,WickhamH.Diagnosticvalueofwritten

referraland/orimagesforskinlesions.JTelemedTelecare2006;12:151-158.


14.TuckerWFG,LewisFM.Digitalimaging:adiagnosticscreeningtool?IntJDermatol

2005;44:479-481.15.BownsIR,CollinsK,WaltersSJ,McDonaghAJG.Telemedicineindermatology:a

randomizedcontrolledtrial.HealthTechnolAssess2006;10:1-39.16.EbnerC,WurmEMT,BinderB,KittlerH,LozziGP,MassoneC,GablerG,Hoffman-Wellenhof

R,SoyerHP.Mobileteledermatology:afeasibilitystudyof58subjectsusingmobilephones.JTelemedTelecare2008;14:2-7.

17.TanE,YungA,JamesonM,OakleyA,RademakerM.Successfultriageofpatientsreferred

toaskinlesionclinicusingteledermoscopy(IMAGEITtrial).BrJDermatol2010;162:803-811.

18.SilvaCS,SouzaMB,DuqueIA,deMedeirosLM,MeloNR,AraujoCD,CriadoPR.

Teledermatology:diagnosticcorrelationinaprimarycareservice.AnBrasDermatol2009;84:489-493.

19.HeffnerVA,LyonVBBrousseauDC,HollandKE,YenK.Store-andforwardteledermatology

versusin-personvisits:acomparisoninpediatricdermatologyclinic.JAmAcadDermatol2009;60:956-961.

20.RibasJ,daGracaSouzaCunhaM,SchettiniAPM,daRochaRibasCB.Agreementbetween

dermatologicaldiagnosesmadebyliveexaminationcomparedtoanalysisofdigitalimages.AnBrasDermatol2010;85:441-447.

21.RubegniP,NamiN,CeveniniG,PoggialiS,Hofmann-WellenhofR,MassoneC,BilenchiR,

BartaliniM,CappelliR,FimianiM.Geriatricteledermatology:store-and-forwardvs.face-to-faceexamination.JEuroDermatol2011;25:1334-1339.

22.LamelSA,HaldemanKM,ElyH,KovarikCL,PakH,ArmstrongAW.Applicationofmobile

teledermatologyforskincancerscreening.JAmAcadDermatol2012;67:576-581.23.KaliyadaF,AminTT,KuruvillaJ,AlBuAliWH.Mobileteledermatology–patient

satisfaction,diagnosticandmanagementconcordance,andfactorsaffectingpatientrefusaltoparticipateinSaudiArabia.JTelemedTelecare2013;19:315-319.

24.AguileraGR,delCallePC,IglesiasEV,CamineroPS,ArpaMG,MartinJAG.Interobserver

reliabilityofstore-and-forwardteledermatologyinaclinicalpracticesetting.ActasDermosifiliogr2014;105:605-613.

25.NamiN,MassoneC,RubegniP,CeveniniG,FimianiM,Hofmann-WellenhofR.Concordance

andtimeestimationofstore-and-forwardmobileteledermatologycomparedtoclassicalface-to-faceconsultation.ActaDermVernerol2015;95:35-39.

26.WarshawEM,GravelyAA,NelsonDB.Reliabilityofstoreandforwardteledermatologyfor

skinneoplasms.JAmAcadDermatol2015;72:426-435.


27.BabaM,SeckinD,KapdagliS.Acomparisonofteledermatologyusingstore-and-forward

methodologyalone,andincombinationwithWebcameravideoconferencing.JTelemedTelecare2005;11:354-360.

28.Moreno-RamirezD,FerrandizL,BernalA,CarrascoD,MartinJ,CamachoF.

Teledermatologyasafilteringsysteminpigmentedlesionclinics.JTelemedTelecare2005;11:298-303.

29.Moreno-RamirezD,FerrandizL,Nieto-GarciaA,CarrascoR,Moreno-AlvarezP,GaldeanoR,

BidegainE,Rios-MartinJJ,CamachoFM.Storeandforwardteledermatologyinskincancertriage:experienceandevaluationof2009teleconsultations.ArchDermatol2007;143:479-484.

30.EdisonKE,WardDS,DyerJA,LaneW,ChanceL,HicksLL.Diagnosis,diagnosticconfidence,

andmanagementconcordanceinlive-interactiveandstore-and-forwardteledermatologycomparedtoin-personexamination.Telemede-Health2008;14:889-895.

31.SenelE,BabaM,DurduM.Thecontributionofteledermatoscopytothediagnosisand

managementofnon-melanocyticskintumours.JTelemedTelecare2013;19:60-63.32.LesherJL,DavisLS,GourdinFW,EnglishD,ThompsonWO.Telemedicineevaluationof

cutaneousdiseases:ablindedcomparativestudy.JAmAcadDermatol1998;38:27-31.33.GilmourE,CampbellSM,LoaneMA,EsmailA,GriffithsCEM,RolandMOetal.Comparison

ofteleconsultationsandface-to-faceconsultations:preliminaryresultsofaUnitedKingdommulticentreteledermatologystudy.BrJDermatol1998;139:81-87.

34.LowittMH,KesslerII,KauffmanCL,HooperFJ,SiegelE,BurnettJW.Teledermatologyand

in-personexaminations:acomparisonofpatientandphysicianperceptionsanddiagnosticagreement.ArchDermatol1998;134:471-476.

35.LoaneMA,CorbettR,BloomerSE,EedyDJ,GoreHE,MathewsCetal.Diagnosticaccuracy

andclinicalmanagementbyrealtimeteledermatology.ResultsfromtheNorthernIrelandarmsoftheUKMulticentreTeledermatologyTrial.JTelemedTelecare1998;4:95-100.

36.PhillipsCM,BurkeWA,ShechterA,StoneD,BalchD,GustkeS.Reliabilityofdermatology

teleconsultationswiththeuseofteleconferencingtechnology.JAmAcadDermatol1997;37:398-402.

37.PhillipsCM,BurkeWA,AllenMH,StoneD,WilsonJL.Reliabilityoftelemedicinein

evaluatingskintumors.TelemedJ1998;4:5-7.38.NordalEJ,MosengD,KvammenB,LochenM-L.Acomparativestudyofteleconsultations

versusface-to-faceconsultations.JTelemedTelecare2001;7:257-265.


39.EminovicN,WitkampL,RavelliACJ,BosJD,vanderAkkerTW,BouseamMTetal.Potentialeffectofpatient-assistedteledermatologyonoutpatientreferralrates.JTelemedTelecare2003;9:321-327.

40.DuMoulinMFMT,Bullens-GoessensYIJM,HenquetCJM,BrunenbergDEM,deBruyn-

Geraerds,WinkensRAGetal.Thereliabilityofdiagnosisusingstore-and-forwardteledermatology.JTelemedTelecare2003;9:249-252.

41.KrupinskiEA,LeSueurB,EllsworthL,LevineN,HansenR,SilvisNetal.Diagnosticaccuracy

andimagequalityusingadigitalcameraforteledermatology.TelemedJ1999;5:257-263.42.HarrisonPV,KirbyB,DickinsonY,SchofieldR.Teledermatology–hightechnologyornot?J

TelemedTelecare1998;4(S1):31-32.43.WhitedJD,MillsBJ,DruggeRJ,GrichnikJM,SimelDL.Apilottrialofdigitalimaginginskin

cancer.JTelemedTelecare1998;4:108-112.44.LozziGP,SoyerHP,MassoneC,MicantonioT,KraenkeB,FargnoliMC,Fink-PurchesR,

BinderB,DiStefaniA,Hofmann-WellenhofR,PerisK.Theadditivevalueofsecondopinionteleconsultinginthemanagementofpatientswithchallenginginflammatory,neoplasticskindiseases:abestpracticemodelindermatology?JEurAcadDermatolVenerol2007;21:30-34.

45.WarshawEM,LederleFA,GrillJP,GravelyMA,BangerterAK,FrotierLA,BohjanenKA,Chen

K,LeePK,RabinovitzHS,JohrRH,KayeVN,BowersS,WennerR,AskariSK,KedrowskiDA,NelsonDB.Accuracyofteledermatologyfornonpigmentedneoplasms.JAmAcadDermatol2009;60:579-588.

46.WarshawEM,LederleFA,GrillJP,GravelyAA,BangerterAK,FortierLA,BohjanenKA,Chen

K,LeePK,RabinovitzHS,JohrRH,KayeVN,BowersS,WennerR,AskariSK,KedrowskiDA,NelsonDB.Accuracyofteledermatologyforpigmentedlesions.JAmAcadDermatol2009;61:753-765.

47.Rios-YuilJM.Correlationbetweenface-to-faceassessmentandtelemedicineforthe

diagnosisofskindiseaseincaseconferences.ActasDermosifiliogr2012;103(2):138-143.48.RomeroG,SanchezP,GarciaM,CortinaP,VeraE,GarridoJA.Randomizedcontrolledtrial

comparingstore-and-forwardteledermatologyaloneandincombinationwithwebcameravideoconferencing.ClinExpDermatol2009;35:311-317.

49.BarbieriJS,NelsonCA,WilliamJD,MargolisDJ,Littman-QuinnR,KovarikCL,RosenbachM.

Thereliabilityofteledermatologytotriageinpatientdermatologyconsultations.JAMADermatol2014;150:419-424.

50.FerrandizL,Moreno-RamirezD,Nieto-GarciaA,CarrascoR,Moreno-AlvarezP,GaldeanoR,

BidegainE,Rios-MartinJJ,CamachoFM.Teledermatology-basedpresurgicalmanagementformelanomaskincancer:apilotstudy.DermatolSurg2007;33:1092-1098.


51.PakHS,HardenD,CruessD,WelchML,PropatichR.Teledermatology:anintraobserverdiagnosticcorrelationstudy,partII.Cutis2003;71:476-480.

52.ShaprioM,JamesWD,KesslerR,LazorikFC,KatzKA,TamJetal.Comparisonofskinbiopsy

triagedecisionsin49patientswithpigmentedlesionsandskinneoplasms.ArchDermatol2004;140:525-528.

53.VanderHeijdenJP,ThijssingL,WitkampL,SpulsPI,deKeizerNF.Accuracyandreliabilityof

teledermatoscopywithimagestakenbygeneralpractitionersduringeverydaypractice.JTelemedTelecare2013;19:320-325.

54.MarcinJP,NesbittTS,ColeSL,KnuttelRM,HiltyDM,PrescottPT,etal.Changesin

diagnosis,treatment,andclinicalimprovementamongpatientsreceivingtelemedicineconsultations.TelemedEHealth2005;11:36-43.

55.PakH,TriplettCA,LindquistJH,GrambowSC,WhitedJD.Store-and-forward

teledermatologyresultsinsimilarclinicaloutcomestoconventionalclinic-basedcare.JTelemedTelecare2007;13;26-30.

56.KrupinskiEA,EngstromM,BarkerG,LevineN,WeinsteinRS.Thechallengesoffollowing

patientsandassessingoutcomesinteledermatology.JTelemedTelecare2004;10:21-24.57.WhitedJD,WarshawEM,KapurK,EdisonKE,ThottapurathuL,RajuS,CookB,EngasserH,

PullenS,MoritzTE,DattaSK,MartyL,FomanNA,SuwatteeP,WardDS,RedaDJ.Clinicalcourseoutcomesforstoreandforwardteledermatologyversusconventionalconsultation:arandomizedtrial.JTelemedTelecare2013;19:197-204.

58.LamelS,ChambersCJ,RatnararthornM,ArmstrongAW.Impactofliveinteractive

teledermatologyondiagnosis,diseasemanagement,andclinicaloutcomes.ArchDermatol2012;148:61-65.

59.FruhaufJ,KrockS,QuehenbergerF,KoperaD,Fink-PuchesR,KomerickiP,PucherS,

ArzbergerE,Hofmann-WellenhofR.Mobileteledermatologyhelpingpatientscontrolhigh-needacne:arandomizedtrial.JEurAcadDermatolVener2015;29:919-924.

60.WilliamsTL,MayCR,EsmailA,GriffithsCEM,ShawNT,FitzgeraldDetal.Patient

satisfactionwithteledermatologyisrelatedtoperceivedqualityoflife.BrJDermatol2001;145:911-917.

61.FruhaufJ,SchwantzerG,Ambros-RudolphCM,WegerW,Ahlgrimm-SiessV,SalmhoferW,

Hofmann-WellenhofR.Pilotstudyontheacceptanceofmobileteledermatologyforthehomemonitoringofhigh-needpatientswithpsoriasis.AustralasJDermatol2012;53:41-46.

62.FruhaufJ,SchwantzerG,Ambros-RudolphCM,WegerW,Ahlgrimm-SiessV,SalmhoferW,

Hofmann-WellenhofR.Pilotstudyusingteledermatologytomanagehigh-needpatientswithpsoriasis.ArchDermatol2010;146:200-201.


63.WhitedJD,WarshawEM,EdisonKE,KapurK,ThottapurathuL.RajuS,CookB,EngasserH,PullenS,ParksP,SindowskiT,MotykaD,BrownR,MoritzTE,DattaSK,ChrenM,MartyL,RedaDJ.Effectofstoreandforwardteledermatologyonqualityoflife;arandomizedtrial.JAMADermatol2013;149:584-591.

64.AlQuranHA,KhaderYS,EllauziZM,ShdaifatA.Effectofreal-timeteledermatologyon

diagnosis,treatment,andclinicalimprovement.JTelemedTelecare2015;21:93-99.65.HsuehMT,EastmanK,McFarlandLV,RaugiGJ,ReiberGE.Teledermatologypatient

satisfactioninthePacificNorthwest.Telemede-Health2012;18:377-381.66.WeinstockMA,NguyenFQ,RisicaPM.Patientandprovidersatisfactionwith

teledermatology.JAmAcadDermatol2002;47:68-72.67.PakHS,WelchM,PoropatichR.Web-basedteledermatologyconsultsystem:preliminary

resultsfromthefirst100cases.StudHealthTechnolInform1999;64:179-184.68.KvedarJC,MennER,BaradaguntaS,Smulders-MeyerO,GonzalezE.Teledermatologyina

capitateddeliverysystemusingdistributedinformationarchitecture:designanddevelopment.TelemedJ1999;5:357-366.

69.VandenAkkerThW,RekerCHM,KnolA,PostJ,WilbrinkJ,vanderVeenJPW.

Teledermatologyasatoolforcommunicationbetweengeneralpractitionersanddermatologists.JTelemedTelecare2001;7:193-198.

70.CollinsK,WaltersS,BownsI.Patientsatisfactionwithteledermatology:quantitativeand

qualitativeresultsfromarandomizedcontrolledtrial.JTelemedTelecare2004;10:29-33.71.WhitedJD,HallRP,FoyME,MarbreyLE,GrambowSC,DudleyTK,DattaSK,SimelDL,

OddoneEZ.Patientandcliniciansatisfactionwithastore-and-forwardteledermatologyconsultsystem.TelemedJ2004;10:422-431.

72.CollinsK,BownsI,WaltersS.Generalpractitioners’perceptionsofasynchronous

telemedicineinarandomizedcontrolledtrialofteledermatology.JTelemedTelecare2004;10:94-98.

73.LavanyaJ,GohKW,LeowYH,ChioMTW,PrabaharnK,KimY,SohCB.Distributedpersonal

healthinformationmanagementsystemfordermatollgyatthehomesforseniorcitizens.ConfProcIEEEMedBiolSoc2006;1:6312-6315.

74.OuMH,WestGAW,LazarescuM,ClayCD.EvaluationofTELEDERMfordermatological

servicesinruralandremoteareas.ArtifIntellMed2008;44:27-40.75.McFarlandLV,RaugiGJ,ReiberGE.Primarycareproviderandimagingtechnician

satisfactionwithateledermatologyprojectinruralVeteransHealthAdministrationclinics.Telemede-Health2013;19:815-825.


76.ReidDS,WeaverLE,SargeantJM,AllenMJM,MasonWF,KlotzPJetal.TelemedicineinNovaScotia:areportofapilotstudy.TelemedJ1998;4:249-258.

77.LoaneMA,BloomerSE,Corbett,EedyDJ,GoreHE,MathewsCetal.Patientsatisfaction

withrealtimeteledermatologyinNorthernIreland.JTelemedTelecare1998;4:36-40.78.HicksLL,BolesKE,HudsonS,KlingB,TracyJ,MitchellJetal.Patientsatisfactionwith

teledermatologyservices.JTelemedTelecare2003;9:42-45.79.JonesDH,CrichtonC,MacdonaldA,PottsS,SimeD,TomsJetal.Teledermatologyinthe

HighlandsofScotland.JTelemedTelecare2(S1):7-9.Recentliteraturewhichispertinent,butwasnotincludedinthereview:80.AshfaqA.Marghoob,MDfortheInternationalSkinImagingCollaborationMelanomaProject

WorkingGroups.StandardsinDermatologicImaging.JAMADermatol2015;151:819-821.81.QuigleyEA,TokayBA,JewellST,MarchettiMA,HalpernAC. TechnologyandTechniqueStandardsforCamera-AcquiredDigitalDermatologicImagesA

SystematicReview.JAMADermatol2015;151:883-890.

82.LandowSM,OhDH,WeinstockMA.TeledermatologyWithintheVeteransHealthAdministration,2002-2014.TelemedJEhealth2015;21:769-773.

83.LivingstoneJ,SolomonJ.Anassessmentofthecost-effectiveness,safetyofreferraland

patientsatisfactionofageneralpracticeteledermatologyservice.LondonJPrimaryCare2015;7:31-35.

84.SharmaP,KovarikCL,LipoffJB.Teledermatologyasameanstoimproveaccesstoinpatientdermatologycare.JTelemedTelecare2015;Publishedaheadofprintdoi:10.1177/1357633X15603298.

85.DattaKS,WarshawEM,EdisonKE,KapurK,ThottapurathuL,MoritzTE,RedaDJ,WhitedJD.

CostandUtilityAnalysisofaStore-and-ForwardTeledermatologyReferralSystem:ARandomizedClinicalTrial.JAMADermatology2015;151:1323-1329.

86.RaugiGJ,NelsonW,MiethkeM,BoydM,MarkhamC,BDougallB,BrattenD,TComerT.

TeledermatologyImplementationinaVHASecondaryTreatmentFacilityImprovesAccesstoFace-to-FaceCare.TelemedJE-health2015;Epubaheadofprint.

87.Moreno-RamírezD,FerrándizL.A10-YearHistoryofTeledermatologyforSkinCancer

Management.JAMADermatol2015;151:1289-1290. 88.AmericanTelemedicineAssociationTelemedicinePracticeGuidelines.

http://www.americantelemed.org/resources/telemedicine-practice-guidelines/telemedicine-practice-guidelines/practice-guidelines-for-teledermatology#.Vs9cGblIiM8lastaccessedFebruary25,2016.

new ata teledermatology practice guidelines

Documents