ORIGINAL RESEARCH
Evaluation and Comparison of Store-and-Forward Teledermatology Applications April W. Armstrong, M.D.,1 Christopher Sanders,1 Aron D. Farbstein,2 George Z. Wu,2 Steven W. Lin, M.D.,1 Fu-Tong Liu, M.D., Ph.D.,1 and Thomas S. Nesbitt, M.D., M.P.H.2 1
Department of Dermatology and 2Center for Health and Technology, University of California, Davis, Sacramento, California.
Abstract Objective: Store-and-forward (S&F) teledermatology has been used to increase patient access to dermatologic care. A major challenge to implementing S&F teledermatology is selecting secure and costsaving applications for data capture and transmission. Detailed analyses and comparison of the major S&F teledermatology applications do not exist in the current peer-reviewed literature. The objectives of this study were to identify, evaluate, and compare the major S&F teledermatology applications in the United States to help referral and consultant sites select applications responsive to their needs. Materials and Methods: We identified four major, commercially available S&F teledermatology applications after surveying the members of the American Telemedicine Association Teledermatology Special Interest Group and the Telemedicine Task Force of the American Academy of Dermatology. A multidisciplinary team of dermatologists, primary care physicians, and information technologists established a set of criteria used to evaluate the applications. We performed a comparative analysis of the four major S&F teledermatology applications based on the predetermined evaluation criteria. Results: The four major, commercially available S&F teledermatology applications evaluated in this study were Alaska Federal Health Care Access Network, Medweb, TeleDerm Solutions, and Second Opinion. All four teledermatology applications were mature
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and capable of addressing the basic needs of S&F teledermatology referrals and consultations. Each application adopts different approaches to organize medical information and facilitate consultations. Areas in need of improvement common to these major applications include (1) increased compatibility and integration with established electronic medical record systems, (2) development of fully integrated billing capability, (3) simplifying user interface and allowing user-designed templates to communicate recommendations and patient education, and (4) reducing the cost of the applications. Conclusion: The four major S&F teledermatology applications in the United States are versatile applications capable of facilitating communication between referral and consultant sites. Continued efforts in making these applications more secure, robust, userfriendly, and affordable will contribute to wider implementation of S&F teledermatology. Key words: dermatology, teledermatology, telehealth
Introduction
T
eledermatology is the practice of delivering dermatological care via communication technology. In the United States, teledermatology has been used primarily to improve access to dermatological care in rural and medically underserved communities.1 Store-and-forward (S&F) teledermatology, the most common form of teledermatology, entails capturing of clinical data and digital images for asynchronous review by a dermatologist.2 Studies that compared S&F teledermatology with conventional, face-to-face care have suggested several advantages of S&F teledermatology.3,4 S&F teledermatology appears to improve patient access, provide costeffective care, and increase distance medical education.5–9 Despite the reported advantages of S&F teledermatology, wide implementation in the United States has faced several real-world
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COMPARATIVE ANALYSIS OF S&F TELEDERMATOLOGY APPLICATIONS
challenges.10 These include fragmentation of the reimbursement system, a paucity of affordable and user-friendly S&F teledermatology applications, lack of adequate referral site training for image and data capture, and a need for improved communication between dermatologists and referring providers.1 Among these obstacles, the lack of affordable and intuitive S&F teledermatology applications presents a practical and persistent challenge for referral sites and dermatologists interested in participating in S&F teledermatology. Few S&F teledermatology applications are currently available commercially in the United States. For referral sites and dermatologists interested in initiating an S&F teledermatology program, selection of an S&F teledermatology application can be a confusing process. Choosing an appropriate S&F application will depend upon factors including clinical setting, consult volume, and financial considerations. To date, no study has evaluated and compared the major S&F teledermatology applications in the United States. The specific aims of this project are to identify the major S&F teledermatology applications in the United States, establish criteria for assessment, and critically evaluate these applications based on the identified criteria. We anticipate that this comparative analysis will assist dermatologists and referring providers from various practice settings to make more informed decisions when evaluating and selecting an appropriate S&F teledermatology application.
Materials and Methods SELECTION OF MAJOR S&F APPLICATIONS To select the major S&F teledermatology applications for this study, we queried all members of the American Telemedicine Association Teledermatology Special Interest Group and the American Academy of Dermatology Telemedicine Task Force. Based on their responses, we generated a preliminary list of S&F teledermatology applications for consideration. We excluded S&F teledermatology applications that are not commercially available. We discussed with the leadership from both organizations and decided on the four major, commercially available S&F applications: Alaska Federal Health Care Access Network (AFHCAN), Medweb, TeleDerm Solutions, and Second Opinion.
DETERMINATION OF EVALUATION CRITERIA A multidisciplinary team was assembled, which consisted of five board-certified dermatologists, five primary care physicians, and two information technologists from the University of California Davis Center for Health and Technology. The team generated an initial list of potential evaluation criteria for the S&F teledermatology appli-
cations. We presented this list of evaluation criteria to three experienced teledermatologists and refined the evaluation criteria based on their feedback.
EVALUATION OF MAJOR S&F TELEDERMATOLOGY APPLICATIONS To compare the major S&F teledermatology applications, three groups of individuals performed the evaluation of the applications: information technologists, new users, and experienced users (highvolume users). Overview and technical evaluation. Two information technologists from the University of California Davis Center for Health and Technology evaluated each application according to security, compatibility, creating a case, responding to a case, and searching cases. New user evaluation. All four applications were tested by three independent, first-time users: two board-certified dermatologists and one dermatology clinical researcher. The new users were asked to evaluate each application for user-friendliness and image-viewing capabilities. High-volume teledermatologist perspective. A high-volume teledermatologist (HVT) is defined as a dermatologist who performs at least 20 S&F teledermatology consultations per month using a particular application. At least one HVT was identified for each of the four applications. We performed in-depth, one-on-one interviews with each HVT regarding their experience and satisfaction with each application.
Results The evaluation criteria developed by the multidisciplinary team entail the following categories: system requirements, Health Insurance Portability and Accountability Act compliance and privacy, information sharing and storage, user interface, compatibility, scalability, billing, and cost (Table 1). The results of the evaluation are summarized in Table 2. In this section, we present the aspects of our evaluation that will be relevant and practical for healthcare professionals when selecting an S&F teledermatology application.
ALASKA FEDERAL HEALTH CARE ACCESS NETWORK Overview and technical evaluation. AFHCAN has been in use since 1999 and has been implemented at over 340 sites in Alaska. A client
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Table 1. Evaluation Criteria for Store-and-Forward Teledermatology Applications EVALUATION CRITERIA
DESCRIPTION
System requirements
Resources required to operate the program. Ability to run on a local computer versus Web accessibility.
HIPAA compliance, security, and privacy
HIPAA compliance with secure storage, transmission, and access.
Information sharing and storage
Ability to store and transmit digital images, clinical history, and consultant recommendations in an organized and searchable fashion.
User interface
User-friendliness and intuitiveness of the application. Upload speed for digital images.
Compatibility
Integration with existing EMR systems and applications. Ability to interface with standard imaging communication formats such as DICOM and PACS.
Scalability
Ability to fit into organizations of various sizes and functionalities.
Billing
Ability to upload, capture, and=or process billing information directly to a third-party payer.
Cost
License, server, and user costs.
DICOM, digital imaging and communications in medicine; EMR, electronic medical records; HIPAA, Health Insurance Portability and Accountability Act; PACS, picture archiving and communication system.
Table 2. Summary of Feature Comparison Among the Four Major Store-and-Forward Teledermatology Applications EVALUATION CRITERIA
DESCRIPTION
AFHCAN
MEDWEB
TELEDERM SOLUTIONS
SECOND OPINION
System requirements
Resources required to operate the program. Ability to run on a local computer versus Web accessibility.
The referral side runs an application local to the PC. Consulting physicians use Internet Explorer or Firefox to access the cases.
PC with Microsoft Pentium class PC with Windows 2000 (or higher) 500 MB RAM running Inand an Internet ternet Explorer 5 or later. connection running Internet Explorer 5.5 Service Pack 2 or later.
PC with Microsoft Windows XP and Microsoft Office. Client software is currently only compatible with Microsoft Windows XP. Accessible via the Web using terminal services technologies such as Citrix. Second Opinion also has a WebAccess product not evaluated here.
HIPAA compliance, security, and privacy
HIPAA compliance with secure storage, transmission, and access.
Data are encrypted. Patient information access record is tracked.
Data are encrypted. Patient information access record is tracked.
Data transfer encrypted via HTTPS. Hosted Service is from a Tier-1 data center approved by the VA.
Local client. Data are encrypted and sent over e-mail.
Information sharing and storage
Ability to store and transmit digital images, clinical history, and consultant recommendations in an organized and searchable fashion.
Images can be uploaded from file or captured from medical peripherals. Patient data are stored in a central location where it is easily accessible.
Images can be uploaded from file or captured from medical peripherals. Patient data are stored in a central location where it is easily accessible.
Images can be uploaded from file or captured from medical peripherals. Patient data are stored in a central location where it is easily accessible.
Database is installed locally by default but can be configured for access from a centralized location. Images are uploaded from file.
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Table 2. Summary of Feature Comparison Among the Four Major Store-and-Forward Teledermatology Applications continued EVALUATION CRITERIA
DESCRIPTION
AFHCAN
MEDWEB
TELEDERM SOLUTIONS
User interface
User-friendliness and intuitiveness of the application. Upload speed for digital images.
Features intuitive interface with large clickable buttons (suitable for touch screen). Web interface features e-mail–like layout similar to Microsoft Outlook. Patient case data can be entered on user-customizable forms.
Patient data are entered in a tabbed form. Provides a library of customizable forms.
Intuitive workflow. A database of dermatologyspecific templates enhances efficiency.
The user interface utilizes standard Microsoft icons. Patient information is organized in an intuitive fashion.
Compatibility
Integration with existing EMR systems and applications. Ability to interface with standard imaging communication formats such as DICOM and PACS.
Limited support for PACS and DICOM (requires customization). Does not currently support HL7.
Supports PACS, DICOM, and HL7. HL7 export utility is a custom integration project.
HL7 compatibility would require customization. No DICOM or PACS compatibility.
Does not support ‘‘out of box’’ HL7 or PACS compatibility.
Scalability
Ability to fit into organizations of various sizes and functionalities.
Scalable
Scalable
Scalable
Additional configuration and resources may be required for large deployments.
Billing
Ability to upload, capture, Creates a billing report form and=or process billing that can be sent to any information directly to a system. third-party payer.
Has embedded ICD-9 and Billing integration CPT code libraries. The requires customization. uploading process to another system has to be defined.
Cost (as of July 2009)
License, server, and user costs.
*$17,500 for the server software and hardware including one practice application (dermatology). Additional installation, training, and service fees apply.
Distributed worldwide by AMD Global Telemedicine, Inc. tConsult Server: Perpetual Use License ranges from *$2,500 to *$20,000 depending on size of deployment. tConsult PC Client: Each referral site pays *$3,700 for a Perpetual Use License. tConsult Web Client: This Internet Explorer-based application is free of charge for consulting physicians. Details in text.
*$3,500 ‘‘start-up fee’’ per location, which pays for their staff to provide on-site training. Thereafter, consulting dermatologists pay a $4 transaction fee per consult. Referral sites pay an annual maintenance fee of *$500.
SECOND OPINION
Billing integration requires customization.
Referral sites pay an average of *$2,500 for the basic version=network node and *$5,000 per site for a full version of Second Opinion Professional. Expert Edition is free for consultants.
AFHCAN, Alaska Federal Health Care Access Network; HTTPS, hypertext transfer protocol secure; PC, personal computer; RAM, random access memory; HL7, Health Level Seven; VA, veterans administration; ASP, application service provider; CPT, current procedural terminology; ICD-9, International Classification of Diseases, Ninth Revision.
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application (tConsult Cart) can be locally installed on any Windowsbased personal computer (PC) and used to gather patient information, including the capture and display of data from attached biomedical peripherals. Once relevant data have been entered and uploaded as a ‘‘case’’ from the tConsult Cart, a Web service (tConsult Web) allows consulting doctors to securely access and respond to cases using Internet Explorer or Firefox. This Web service can be hosted and maintained by either AFHCAN or the customer’s own information technology department. Security: Access to tConsult Web is encrypted via a secured socket layer (SSL) (a common method of Internet encryption, indicated by a lock icon in the Web browser’s lower right-hand corner). Major security features include (1) the provisions that users can only send cases to recipients who are preconfigured in the AFHCAN system or by an administrator and (2) both tConsult Cart and tConsult Web maintain detailed history of all patient record activity, which is easily available for user view. Compatibility: At the time of this review, AFHCAN 4.9 did not support Health Level Seven (HL7). Integration with existing picture archiving and communication system (PACS) and digital imaging and communications in medicine (DICOM) system would require customization with an associated higher cost. Creating a case (referring provider): AFHCAN 4.9 tConsult Cart software is available as either a stand-alone software client (which can be installed on any PC) or as part of a fully integrated telemedicine system. The software interface was designed for potential use with a touch screen and thus features large clickable buttons with an intuitive workflow. At the opening screen, clicking the ‘‘Create a New Case’’ button leads to a screen with 15 buttons (Fig. 1A) where a referring provider can enter ‘‘Patient’’ information, fill out ‘‘Forms,’’ and upload images and data from a wide variety of sources and peripherals. In contrast to most S&F applications, which require a sequential or regimented workflow, tConsult Cart allows for greater flexibility in creating cases by allowing users to enter images and pictures in any order. Selecting the ‘‘Forms’’ button brings up a list of standardized patient information forms. Depending on preference, users can also customize their own online forms, a feature unique to this application. Once all necessary data have been entered, captured, and=or uploaded, the user clicks the ‘‘Done’’ and ‘‘Send’’ buttons to transmit the case to the recipient(s). Additional information can only be added to a case while it is ‘‘open.’’ All activity is synchronized between users who have previously accessed the case. Once a case is ‘‘archived,’’ users can only add comments.
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tConsult Cart is optimized for a touch screen, but is easily used with a mouse. Pages that are too long to fit into the window are vertically navigated with clickable arrow buttons rather than the familiar scroll bar. Mouse scroll-wheels will not work in tConsult Cart. Responding to a case (consulting physician): Consulting dermatologists log in to tConsult Web to access cases. This interface (Fig. 1B) is similar to Microsoft Outlook. With an interface modeled after common e-mail applications, the consultants will likely find tConsult Web straightforward and intuitive. Searching cases: ‘‘Archived’’ cases can be searched via the following data: . Patient name . SSN . Date of birth . Case number . Date range . Creator name ‘‘Open’’ cases can be searched similarly, but with the following additional parameters: . Providers (active=inactive) . Groups (active=inactive) . Case type (real=test) . Case location (local=remote) Depending on the search parameter used, results may be grouped accordingly, such as by sending provider or patient name. Users can also use the case list-sorting options and expand results until they identify the case of interest. The noteworthy features of the AFHCAN 4.9 application include the following: (1) Despite having features that favor use with a touch screen, it is easy to navigate with a mouse; (2) When creating a case, an inherent security feature of tConsult prohibits users to remove or change images or attachments once they have been uploaded; and (3) unlike most S&F applications, AFHCAN 4.9 has a form creation tool that allows users to customize patient information forms. Cost information for AFHCAN as well as for the other applications is summarized in Table 2. Further, our research and communication with AFHCAN yielded the following additional cost information. First, when purchasing tConsult Server, users are advised to budget approximately $3,000 for server hardware and about $2,000 for Microsoft licenses. Second, AMD Global Telemedicine, Inc., can host tConsult Server under a secure application service provider model starting at $1,000 per month. Third, after the 1-year warranty expires, ongoing service and technical support are available for 20% of the initial fee per year.
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Fig. 1. (A) tConsult’s home screen to create a new consult from the referring physician’s perspective. (B) Consulting dermatologist’s view of a new consult (tConsult Web). (C) Image display (tConsult Web).
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New user evaluation. The tConsult Web application is aesthetically simple. The similarities it shares to some of today’s e-mail applications will make it familiar to most users (Fig. 1B). Most options, such as reply or upload, are easily selected as hyperlinks (commands that are activated by clicking on the highlighted word or icon on the screen). Reponses from the consulting and referring providers are vertically tiled, organized into a conversation-like format by keeping all responses in order. Documents and photos can be easily uploaded from the user’s hard drive (Fig. 1C). Users should be aware that once an attachment has been uploaded, it cannot be removed from the case, even prior to submitting the response. For example, if the user adds an incorrect attachment, the application does not allow presubmission editing to replace the erroneous attachment with a correct attachment. This application offers several other user-friendly functions, including detailed search options, capability to print both the case and billing report, and the ability to create quick lists of patients, providers, or groups of providers. Overall, AFHCAN 4.9’s intuitive e-mail-like lay out makes it simple for a beginner to learn. AFHCAN 4.9 is Internet accessible, and no software installation or plug-in downloads are required. HVT perspective. Our HVT has used AFHCAN’s tConsult since 2002. This HVT enjoys working with tConsult because of its user-friendliness, intuitive features, and accessibility to consulting physicians through a Web interface. The HVT notes that tConsult is especially helpful to providers suffering from ‘‘technophobia,’’ as AFHCAN 4.9 has designed an easy-to-learn S&F application. This HVT particularly likes AFHCAN’s (4.9) large, color-coded icons, well-labeled data entry fields, and simple-to-use search and organizational capabilities. The HVT cites only a few features that could be improved. AFHCAN version 4.9 cannot interface with electronic medical records (EMR) or bill third-party payers directly, two features that are also lacking in the other major S&F teledermatology programs. Overall, the HVT highly recommends this application for its easeof-use, intuitive layout, and efficiency in handling a high volume of consultations.
MEDWEB Overview and technical evaluation. Medweb has been in operation for over 20 years and currently has deployments with over 350 customers. Originally designed for use in radiology, Medweb has evolved to embrace other medical specialties including der-
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matology. Being entirely Web based, the client software is a small Internet Explorer plug-in installed over the Web. Anyone with a PC (Windows 2000 or higher) and Internet access should be able to securely access the Medweb server to create and review cases. Medweb version 7.0.0 offers support for the PACS, DICOM, and HL7 standards. Security: Web access is protected via SSL. Patient-record access is tracked and can be monitored by the Administrator. Compatibility: Medweb stands out in its ability to easily send studies to a DICOM storage device. Medweb 7.0.0 supports PACS, while integration to support HL7 import=export is available for an extra cost. Creating a case (referring provider): Upon logging in and selecting ‘‘Dermatology’’ to start a study, the user is presented with a tabbed data entry form (Fig. 2A). Although comprehensive, there is no provision allowing users to create highly customized data entry forms. However, administrators can select one of two general types of forms: highly structured (multiple check boxes and radio buttons) and semistructured (more free text entry). Images can be easily uploaded from disk or directly from imaging devices connected to the PC. Medweb’s (7.0.0) unique ‘‘Images’’ interface allows users to drag numbers to an anatomical illustration to designate where on the body an image was taken (Fig. 2A). Uploaded images are displayed in thumbnail form and cannot be enlarged for further review or annotated by the referring provider during the case-creation stage. After creating a case, the referring provider has the opportunity to review the case from a consultant’s perspective (including full size images and final screenshot) prior to submitting it. Responding to a case (consulting physician): The consultant dermatologist can review the list of pending cases and their degree of urgency (Fig. 2B). The image viewer on Medweb 7.0.0 has numerous features to annotate and adjust image properties (Fig. 2C). For example, a virtual magnifying glass can be dragged across the image. The dermatologist can enter diagnoses and recommendations on a Web report with additional options to upload supporting documents to the referring provider. Searching cases: Medweb’s (7.0.0) search feature is integrated into the page’s header for easy accessibility. Users can search by patient name or other identifying information and refine their search by ‘‘status’’ (read, unread, etc) and ‘‘in last’’ (dropdown options specifying time frame). Selecting advanced search options allows users to structure a more comprehensive query with additional fields, such as ‘‘Referring Physician’’ and ‘‘Institution Name.’’
COMPARATIVE ANALYSIS OF S&F TELEDERMATOLOGY APPLICATIONS
The technical evaluation revealed that Medweb 7.0.0 has extensive image-handling options and DICOM compatibility. As a complex and feature-rich application, it would likely require more time to learn than the other applications in this review. Because of Medweb’s (7.0.0) security features, once images and attachments are uploaded, they cannot be changed or removed. If incorrect images were accidentally uploaded or if new information comes to light after submitting the case, an addendum will need to be appended to the case. New user evaluation. The new users found that it can take slightly longer to learn to use the rich features and navigate within Medweb 7.0.0 compared with other applications. The new users found that Medweb 7.0.0 organizes the patient information in a well-structured format. Medweb 7.0.0 has developed robust image viewing and annotation functionalities for consulting physicians. The image viewer is rich with features and thus gives the teledermatologists many options for manipulating the images, such as to zoom, rotate, annotate, measure, or label the images. It is easy for consultants to upload additional documents or pictures when responding to a referral. Further, Medweb 7.0.0 has a ‘‘patient education file’’ feature that allows the consultant to attach patient educational materials in common document formats (Fig. 2D). Medweb 7.0.0 is entirely Web based, allowing for easy access for both referring and consultant providers. To run the application properly, users must install browser plug-ins. For users who are not computer savvy, this could be a minor inconvenience. However, Medweb 7.0.0 appears to offer responsive technical support. HVT perspective. The Medweb HVT has used the application since January 2009 and has not previously used any other teledermatology applications. According to this HVT, the Medweb’s (7.0.0) user interface is simple and easy to operate. This HVT particularly likes the image viewer and the concise display of the necessary clinical data within the consult request. Medweb 7.0.0 can only run on a Windows operating system. Accordingly, this HVT believes that lack of Apple platform compatibility is the least desirable feature of the application. However, Mac incompatibility is not unique to Medweb 7.0.0. One workaround solution is to install
Fig. 2. (A) Creating a case with the tab displaying uploading images from a referring physician’s perspective (Medweb). (B) Consulting dermatologist’s view of a list of pending consults (Medweb). (C) Image viewer (Medweb). (D) Consult report construction (Medweb).
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TELEDERM SOLUTIONS Overview and technical evaluation. Although the other S&F products encompass multiple specialties, TeleDerm Solutions is designed specifically for dermatology. As it is completely Web based, users can securely create and access consults from any PC with Internet access. The data entry forms are comprehensive, but there is currently no option that allows the users to customize their own forms. Security: Access to TeleDerm Solutions’ Web site is encrypted via SSL. When creating cases, users are prompted to reconfirm login credentials at several stages, making it virtually impossible for unauthorized users to complete a case started by an authorized user. Compatibility: Although TeleDerm Solutions is not compatible with the PACS and DICOM standards, HL7 compatibility is possible with additional customization. Currently, TeleDerm Solutions works with Internet Explorer 5 or greater. Images must be uploaded from the file and cannot be directly captured from external sources. Creating a case (referring provider): The patient’s medical information is organized into an intuitive, tab-enabled data entry interface (Fig. 3A). When the referring provider is ready to create a new consult, the consult data entry form appears with five ‘‘Complaint’’ tabs (Fig. 3B). Within each ‘‘Complaint’’ tab page, the users will find pertinent fields for data entry, such as ‘‘Patient History,’’ ‘‘Location,’’ ‘‘Review of Symptoms and Labs,’’ ‘‘Diagnosis,’’ and ‘‘Add Images.’’
Fig. 2. (Continued) Windows-based operating system on the Mac, as was the case with this HVT. A drawback of this workaround is the slowing of the computer’s performance as a result. This HVT likes to simplify the interface buttons by which the users can access, navigate, and edit consult forms. Overall, this HVT is very satisfied with Medweb’s 7.0.0 performance in processing his consults.
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Responding to a case (consulting physician): Upon logging in, the consulting dermatologist is presented with the consult management console (Fig. 3C). The other S&F applications ask the users to choose between viewing written clinical information or images, whereas TeleDerm Solutions keeps image thumbnails fixed in a bottom pane regardless of which information tab the dermatologist clicks, providing constant image references, which many users may appreciate. Selecting a thumbnail image launches a Java-based image viewer. After approximately 10 s, the image appears with basic tools for inverting, zooming, flipping, etc. If additional information is required, the user can click ‘‘Need Add’l Info’’ in the upper right, add comments, and submit back to the referring provider. All S&F applications allow users to paste their own generic responses and upload information sheets from their own collection,
COMPARATIVE ANALYSIS OF S&F TELEDERMATOLOGY APPLICATIONS
whereas TeleDerm Solutions contains a large database of dermatology-specific templates and verbiage for five categories. Specifically, the application contains brief paragraph templates in the following categories: Diagnosis, Tests, Procedures, Medications, and Patient Information. These templates allow the dermatologists to respond with detailed explanation and instructions that would otherwise require considerable time to type by free text. For example, in the ‘‘Patient Information’’ dropdown list (Fig. 3D), the application displays a 906-word response for Allergic Contact Dermatitis, which can be included with the consult response for the patient. However, the users cannot modify these templates or create their own templates. However, the dermatologists can edit the template text after it has been imported into the response field. A unique feature of TeleDerm Solutions is that the application allows cases to be assigned to trainees, who can enter a tentative diagnosis. The attending dermatologist must then approve the tentative diagnosis before the case is returned to the referring provider. Thus, this application may serve as a useful teaching tool. Searching cases: Instead of combining all search functions in one place, TeleDerm Solutions lists separate search features as part of the ‘‘Patients’’ and ‘‘Consults’’ pulldown menus. The search parameters for ‘‘Patients’’ include First Name, Last Name, SSN, and Referring Site, whereas searching consults adds additional ‘‘Date’’ and ‘‘flagged’’ fields. There are no options allowing users to search by ‘‘Date of Birth,’’ ‘‘Creator Name,’’ ‘‘Status’’ or ‘‘Case Number’’=‘‘Consult ID.’’ In conclusion, from a technical perspective, TeleDerm Solutions offers one of the most intuitive workflows reviewed here. TeleDerm Solutions does not contain some of the useful features found in other applications, such as assigning urgency to a case, rich graphic manipulation tools, or support for DICOM, PACS, or HL7 standards. Nevertheless, TeleDerm Solutions requires significantly less training to initiate or respond to consults than the other solutions reviewed. The unique database of dermatology-specific templates allows dermatologists to quickly assemble responses.
Fig. 3. (A) Creating a new consult from the referring physician’s perspective (TeleDerm Solutions). (B) Complaint tabs (TeleDerm Solutions). (C) Consultant management console (TeleDerm Solutions). (D) Patient education templates (TeleDerm Solutions). (E) Consultant’s response form (TeleDerm Solutions). (F) Image viewer (TeleDerm Solutions).
New user evaluation. The new users found the consultant response form to be user-friendly and easy to navigate
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simplicity does not appear to compromise the ability to conduct the consult. Our new users commented that the drawback of this image viewer was that the downloading speed could be improved. Several other features that make TeleDerm Solutions convenient include ‘‘Add’l Info’’ quick link that allows the consultant to request further information as needed, the ‘‘Reset Form’’ option that allows the user to instantly clear all fields, and the ‘‘Patient Ed’’ field that houses a large library of patient educational materials. Overall, TeleDerm Solutions is well organized and provides relevant, dermatology-specific options to its users. TeleDerm Solutions is also intuitive with a simple layout that makes it easy to learn. The ability to involve trainees in performing teledermatology consults is unique to TeleDerm Solutions, and this capability reflects that the application was created with medical education in consideration. The aesthetics of the interface may be improved. Being entirely Web based, TeleDerm Solutions is accessible to anyone with a Windows Operating System and Internet connection.
Fig. 3. (Continued)
(Fig. 3E). This window’s layout contains condensed overview of the patient’s demographics and chief complaints. The main body of the consult window is arranged in tabular form, allowing the user to quickly navigate to the sections of interest by selecting the appropriate headers located at the top of the field. Certain fields must be filled out (denoted by asterisks) before the entire consult is considered complete. These fields include ‘‘Primary Diagnosis,’’ ‘‘Follow-Up,’’ ‘‘Agree with PCP Diagnosis’’ and ‘‘Image Quality.’’ The image functions are simple, containing basic features such as magnification and fitting to window (Fig. 3F). The simplicity of the image functions allows new users to learn the viewer quickly. The
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HVT perspective. We interviewed two HVTs who used TeleDerm Solutions. One HVT used the application for 8 years, and the other HVT has used the application for 2 years. Both HVTs found TeleDerm Solutions easy to use and appreciated its simple and efficient design that allows users to quickly respond to consults. The HVTs believe that the application was fully capable of fielding all the necessities of S&F consultations, except for the creation and electronic submission of billing claims. Regarding areas needing improvement, one HVT noted that the application allows the user to upload only one picture at a time, which can be time-consuming. This HVT expressed that the application is based on older technology that could be updated to take advantage of new Web capabilities such as autofill selections. Further, the application’s preset consult responses and patient educational materials cannot be modified by individual users to create individualized templates. Overall, the HVTs praised TeleDerm Solution’s simplicity in design and suggested that the ease of use is attractive to new users considering an application that requires less time for learning. Although the HVTs cited TeleDerm Solutions as utilizing older Web interface technology, they deemed that the application was more than capable of handling consults.
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Fig. 4. (A) Creating a new case from a referring physician’s perspective (Second Opinion). (B) Consultant’s form with ‘‘follow up’’ tab clicked (Second Opinion). (C) Searching a case (Second Opinion). (D) Organization of patient information (Second Opinion).
SECOND OPINION Overview and technical evaluation. Established in 1994, Second Opinion software is currently installed at over 1,800 U.S. and international locations. As Second Opinion offers a range of S&F products for
medical (and even law enforcement) applications, we chose Second Opinion Professional Version 7.07 (for referring providers) and Second Opinion Professional Expert Edition Version 7.0.4 (for consulting providers) for this evaluation given their common use in teledermatology.
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Unlike other applications reviewed here, Second Opinion is designed to be self-installed and maintained by the user. It does not require patient information to be stored in a centralized location. Instead, Second Opinion can be set up to utilize a local set of databases to store cases that the client has either created or received. Cases created and received by other systems utilizing their own local set of databases are not accessible. For larger implementations where physicians may need to access records of patients to whom they have not previously provided care, Second Opinion can be set up to store patient information in a centralized location (this is done by copying the databases and documents to a centralized location and modifying the setup.ini file in the Second Opinion application to point the network share). Second Opinion places the burden of purchase on the referral sites. Second Opinion Professional 7.07 must be purchased by the referral sites to create cases, whereas the consulting providers can review and respond to cases with Second Opinion Professional Expert Edition 7.0.4 at no cost. Security: Second Opinion Professional 7.07 encapsulates patient data in an encrypted (128-bit) file, which can be sent to the desired consulting physician as an e-mail attachment. These files could potentially be intercepted and opened by anyone using Second Opinion software. For this reason, it is best to use Second Opinion’s password protection feature to ensure that only intended recipients can access the patient information. Second Opinion data can also be transmitted in real time from one location to another by utilizing a network connection, thereby eliminating the need to transfer files via e-mails. Compatibility: The Second Opinion client software is currently only compatible with Microsoft Windows XP. Although Second Opinion does not currently support ‘‘out of the box’’ HL7 or PACS compatibility, additional services can be purchased to integrate Second Opinion with existing EMR and PACS systems. Second Opinion can recognize popular medical imaging formats such as DICOM (requires the purchase of an additional DICOM Module). Second Opinion’s database is standards based and can be integrated for compatibility with third-party reporting software (such as Crystal Reports, Microsoft Access, and Visual Foxpro). Creating a case (referring provider): Second Opinion cases are created using the Professional 7.07 version. After logging in, users are prompted to either open an existing case or create a new case. The user selects ‘‘New Folder’’ to created a new case to store patient information (Fig. 4A). After creating a New Folder with the patient’s demographics, referring providers can utilize a variety of capture applications to create images, media clips, database forms, and text documents to
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create the content of the referral. Additional information and content from external devices can also be utilized for the referral using an import feature. Second Opinion has a set of generic Referral and Consultation forms suitable for most medical specialties. For those wishing to design their own forms, Second Opinion includes a free Developer’s Tool Kit, a Custom Form Designer, and a Custom Report Writer utilizing Microsoft Word. When the referring provider completes a case creation, Second Opinion Professional 7.07 can launch the user’s e-mail application with the newly created case attached to a composition. The referring provider sends the e-mail as usual. Responding to a case (consulting physician): The consulting physicians receive an e-mail at a designated e-mail address from Second Opinion Professional 7.07 when they have a new consult. The e-mail contains an encrypted file from Second Opinion Professional 7.07. The receiving computer must also have Second Opinion installed to read the cases, and a free version (Second Opinion Professional Expert Edition 7.0.4) is available for the consultants. All consulting physicians must also register with the vendor for tracking purposes. The consulting physicians responding to the cases can use the included consultation form (Fig. 4B). Multiple consultation forms can be created and linked to the same referral. Follow-up consultations on the same patient are automatically saved in the patient’s folder and sorted by date. Searching cases: The ‘‘Locate Folders’’ feature allows users to search by Name, ID, Status, Creator, and Date (Fig. 4C). An advanced search feature allows users to query all fields in the database by key words. Our technical evaluation of Second Opinion concludes that this application offers an easy to implement and effective S&F solution without the need to subscribe to a hosted service or purchase a centralized server. New user evaluation. Unlike the other applications reviewed, Second Opinion is not inherently Web based. However, it can be accessed via the Web using remote access technologies such as Citrix. Although not reviewed here, Second Opinion has a WebAccess module to support access to Second Opinion data via the Web. In the ‘‘off-the-shelf’’ form of Second Opinion, both the referral providers and dermatologists are required to download the application locally onto their computers. The disadvantage to this lies in the need for multiple installations on multiple computers, which limits the ease of access. Conversely, the advantage of such an application is that, once the encrypted case file is downloaded from the e-mail, the consultants
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can view and work on the cases offline. Once the user downloads new data, all files are stored on that user’s designated hard drive. In our evaluation, the new users liked how Second Opinion organizes a patient’s medical information. All information related to a patient is grouped into one folder with subfolders that contain different categories of information (Fig. 4D). If a patient has a follow-up consult at a later date, the follow-up consult data will be grouped into the same patient’s files. The new users find the consult form simple and straightforward to complete. The form contains three fields: consultation, recommended treatment plan, and recommended follow up=additional comment. The new users also liked that any completed consult can be saved as a separated Word document, which can be printed, faxed, or e-mailed. To ensure the security of e-mail transmission of the consult in worddocument format, the application requires that a password be entered to open the document. Aesthetically clean, the program generates new windows rather than utilizing dropdown menus or multiple fields within a single window. This allows the users to keep multiple documents open at once for rapid accessing of data. A useful feature of this application is to view multiple pictures within a single window. Dragging a picture from the patient folder into the image viewer allows the user to compare several images side by side. With Second Opinion, the users will likely need more instructions and practice to learn how to operate within the application than the other applications evaluated. However, the benefits of robust image viewing capabilities and an intuitive medical record filing system are worth noting. HVT perspective. The HVT for Second Opinion has used the application since 2002. This HVT prefers the option of downloading referrals directly to a hard drive and working with the downloaded files when he is offline. In addition, this HVT likes how Second Opinion organizes the patient information—with subfolders within a patient’s file, much like how a physical patient file is organized. The HVT rated the image viewer to be versatile, efficient, and robust for handling multiple images. The HVT likes the simple consultation fields, where he can cut and paste paragraphs from Microsoft word directly into the consultation fields. A specific improvement that the HVT suggested is the implementation of a billing function within Second Opinion. The lack of a billing feature required the consult to copy and paste billing information into a separate billing application. However, the HVT acknowledges that the lack of comprehensive billing capability is common to all the commercially available S&F applications to date.
Overall, this HVT truly enjoys the organization of patient information as well as the robust image-viewing capabilities of Second Opinion.
Discussion S&F teledermatology is among the most actively practiced form of telemedicine in the United States.11,12 Within this evolving field, evidence suggests that S&F teledermatology can be an effective, reliable, and cost-saving means of increasing dermatologic access.9,10,13–15 The selection of a secure, user-friendly, robust, and affordable S&F teledermatology application is an essential component of establishing an S&F teledermatology program. This study purports to provide a comparative evaluation of the major S&F teledermatology applications by using a set of developed evaluation criteria. The findings from this study may be used as a reference and may help to guide the referring providers and the consulting dermatologists in selecting an application suitable to their needs. The four S&F teledermatology applications evaluated in this study are mature products that have different approaches to organize medical information and facilitate consultations. Each application is capable of handling the basic needs of S&F teledermatology consults, with different approaches to data capture and presentation. There are, however, areas where all four applications need improvement. These include the lack of direct billing integration and limited compatibility with existing EMR systems. AFHCAN has a user interface that is easy to learn from both the referring provider and the consultant dermatologist’s perspectives. The application has a high level of accessibility for consultants through a Web-based component that offers an intuitive ‘‘e-mail– like’’ layout. The designers implemented SSL-encrypted security features to protect patient data for this Web-based application. Medweb has SSL-encrypted security and is entirely Web based, making it highly accessible. Medweb requires installation of plug-ins for the application to run properly. Medweb has broad platform compatibility as it can be used with both Apple and Linux systems in addition to Windows. It has a well-organized, tabular layout for the referrer. The image viewer has the most robust and comprehensive features among the four applications examined. TeleDerm Solution’s user interface is positively simple. Various quick links allow the user to access the same information in multiple ways. TeleDerm Solutions is unique among the other telemedicine programs in that it was designed specifically for dermatology consultations. It is entirely Web based. In addition to SSL encryption, this program has the enhanced security feature of requiring reconfirmation of login credentials at multiple stages of the referral status. Providers can access predesigned patient instructions, consult
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responses, and educational materials for common dermatologic problems, a useful resource for those who find the preset templates suitable for their needs. TeleDerm Solutions is also the only application that allows participation by trainees, such as residents. The strengths of Second Opinion lie in its intuitive organization of a patient’s medical information, the capability to view multiple consults in the same patient, and a robust image viewer where multiple images can be viewed within the same window for side-byside comparison. The ‘‘off-the-shelf’’ version of the application needs to be installed on local computers for use. We found that all four of the applications evaluated in this study were capable of handling S&F dermatological consultations. The areas that will need to be improved for S&F teledermatology platforms in the coming years lie in the following four categories: (1) increased compatibility and integration with EMR systems, (2) development of fully integrated billing capability, (3) simplifying user interface and allowing consultant-designed templates to communicate recommendations and patient education, and (4) reducing the cost of the applications. With continued progress in the field of teledermatology, comparative analysis of existing S&F teledermatology applications and the ability to capture user feedback will drive improvements in the development of S&F teledermatology applications.
Acknowledgments This project was funded by the California HealthCare Foundation. The authors acknowledge Drs. John Bocachica, Marc Goldyne, Joseph Kvedar, Karen Edison, Hon Pak, Bernard Cohen, Nayla Idriss, and Noah Craft for their valuable input in this project. The authors thank the members of the American Telemedicine Association Teledermatology Special Interest Group and the Telemedicine Task Force of the American Academy of Dermatology for their participation in this project. The authors also thank the technology teams at AFHCAN, Medweb, TeleDerm Solutions, and Second Opinion for communicating with the research team regarding the technical evaluation aspect of this project.
Disclosure Statement This project was funded by the California HealthCare Foundation. All authors declare no relevant competing financial interests. REFERENCES 1. Pak H, Edison K, Whited J. Teledermatology: A user’s guide. New York, NY: Cambridge Press, 2008:3–4. 2. Pak H, Burg G. Store-and-forward teledermatology. May 30 2008. Available at http:== emedicine.medscape.com=article=1130993-overview (last accessed July 22, 2009).
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3. Whited JD. Teledermatology research review. Int J Dermatol 2006;45:220–229. 4. Eminovic N, de Keizer NF, Bindels PJ, Hasman A. Maturity of teledermatology evaluation research: A systematic literature review. Br J Dermatol 2007;156:412–419. 5. Lopez AM, Avery D, Krupinski E, Lazarus S, Weinstein RS. Increasing access to care via tele-health: The Arizona experience. J Ambulatory Care Manage 2005;28:16–23. 6. Whited JD, Datta S, Hall RP, Foy ME, Marbrey LE, Grambow SC, Dudley TK, Simel DL, Oddone EZ. An economic analysis of a store and forward teledermatology consult system. Telemed J E Health 2003;9:351–360. 7. Williams CM, Kedar I, Smith L, Brandling-Bennett HA, Lugn N, Kvedar JC. Teledermatology education for internal medicine residents. J Am Acad Dermatol 2005;52:1098–1099. 8. Pak H, Triplett CA, Lindquist JH, Grambow SC, Whited JD. Store-and-forward teledermatology results in similar clinical outcomes to conventional clinicbased care. J Telemed Telecare 2007;13:26–30. 9. Armstrong AW, Dorer DJ, Lugn NE, Kvedar JC. Economic evaluation of interactive teledermatology compared with conventional care. Telemed J E Health 2007;13:91–99. 10. Pak HS. Implementing a teledermatology programme. J Telemed Telecare 2005;11:285–293. 11. Krupinski E, Burdick A, Pak H, Bocachica J, Earles L, Edison K, Goldyne M, Hirota T, Kvedar J, McKoy K, Oh D, Siegel D, Antoniotti N, Camacho I, Carnahan L, Boynton P, Bakalar R, Evans R, Kinel A, Kuzmak P, Madden BC, Peters S, Rosenthal L, Simmons S, Bernard J, Linkous J. American Telemedicine Association’s Practice Guidelines for Teledermatology. Telemed J E Health 2008;14:289–302. 12. Kvedar JC, Edwards RA, Menn ER, Mofid M, Gonzalez E, Dover J, Parrish JA. The substitution of digital images for dermatologic physical examination. Arch Dermatol 1997;133:161–167. 13. Edison KE, Ward DS, Dyer JA, Lane W, Chance L, Hicks LL. Diagnosis, diagnostic confidence, and management concordance in live-interactive and store-andforward teledermatology compared to in-person examination. Telemed J E Health 2008;14:889–895. 14. Massone C, Wurm EM, Hofmann-Wellenhof R, Soyer HP. Teledermatology: An update. Semin Cutan Med Surg 2008;27:101–105. 15. Moreno-Ramirez D, Ferrandiz L, Nieto-Garcia A, Carrasco R, Moreno-Alvarez P, Galdeano R, Bidegain E, Rios-Martin JJ, Camacho FM. Store-and-forward teledermatology in skin cancer triage: Experience and evaluation of 2009 teleconsultations. Arch Dermatol 2007;143:479–484.
Address correspondence to: April W. Armstrong, M.D. Department of Dermatology University of California, Davis 3301 C St., Suite 1400 Sacramento, CA 95816 E-mail:
[email protected] Received: September 15, 2009 Accepted: October 21, 2009
