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Global teledermatology

Rebecca Gaffney

Rutgers Robert Wood Johnson Medical School, USA

E-mail : rgg49@rwjms.rutgers.edu

Babbar Rao

Rutgers Robert Wood Johnson Medical School, USA

DOI: : 10.15761/GOD.1000156

Article
Article Info
Author Info
Figures & Data

Introduction

Telemedicine is the delivery of health care services between two remote locations through information and communication technologies to improve a patient’s health condition.  It is a tool to increase access to quality care services for patients in both developing and developed countries in any situation in which there is a barrier to receiving treatment [1].  There are generally two methods of telemedicine delivery:  store-and-forward and live-interactive.  The store-and-forward modality involves the transfer of digital images with relevant patient information through email or a web-based platform to a specialist in a remote location for consultation.  In live-interactive telemedicine, the patient and/or their healthcare provider meet with the consulting specialist and interact in real time through videoconferencing.  Since its inception about 40 years ago in US hospitals, telemedicine services have expanded across the world and now include many different specialties [2,3].

Dermatology is particularly well suited for telemedicine because it is a visual specialty.  Teledermatology, defined as the remote delivery of dermatological services and clinical information using telecommunications technology, is the second most developed telemedicine service area globally, behind teleradiology [1,4].  Teledermatology is a rapidly growing field due totechnological advancements and because it is seen as a way to address the shortage of dermatologists in rural and underserved communities. The most recent data published on physician needs assessment estimates that the ideal ratio of dermatologist to population ratio is 1:30,000 [5]. This need is largely unmet across the globe, as the International Foundation for dermatology estimates that 3 billion people in 345 developing countries lack basic care for skin diseases [6]. Table 1 demonstrates the disparity in dermatologists around the world [7].

Table 1. Dermatologist-population ratio in different regions of the world

USA

1: 30,000

UK

1: 200,000

Other European Countries

1: 50,000

Asia

1: 2000,000 (Urban)

 

1: 780,000 (rural)

Sub-Sahara countries

1: 1,000,000 (urban)

 

1: 5-50 million (rural)

Central/South America

1: 76,000 (urban)

 

1: 1-66 million (rural)

Much of the current literature on teledermatology solely addresses its validity in healthcare delivery, evaluating diagnostic accuracy, reliability, and patient satisfaction in multiple short-term studies.  However, there are few published works on established programs, pilot projects, or feasibility studies in teledermatology, which would indicate that a country has an existing infrastructure and technology that can develop into a permanent program.  To the best of our knowledge, the prevalence and locations of teledermatology programs have not been assessed globally.  The objective of this paper is to identify established and pilot teledermatology programs across the world.

Methods

This study looked at the 194 member states recognized by the World Health Organization.  We searched the PubMed MEDLINE [in All Fields] and Scopus databases [in Article title, Abstract, and Keywords] for teledermatology programs in each country from 1995 to present.  In our search, we used the terms “teledermatology AND [country]” and “telemedicine OR telehealth AND dermatology AND [country]”. Only articles in English with titles and abstracts that were published online and in print were considered for inclusion.  Search results were then screened and studies were excluded based on title and/or abstract if the study solely measured outcomes of diagnostic reliability and accuracy of teledermatology vs. face-to-face consultation, patient satisfaction with the program, or cost-benefit analysis.  All articles with descriptive studies of established programs, pilot studies, and feasibility studies were reviewed.  The reference lists of identified studies were also searched for further relevant studies.

Results

Of the 194 countries searched in the literature, 81 were found to have an established teledermatology program, a telemedicine program that includes dermatology, a pilot project in teledermatology, or a feasibility study in teledermatology.  The study found 153 total programs globally. Among both active and non-active teledermatology programs, a majority (86%) of programs used store-and-forward as the method of delivery.  The remainder of programs used live-interactive, a combination, or an unknown method of delivery. 

There was a total of 133 sustained teledermatology programs or active pilot projects around the globe (Figure 1).  These programs include store-and-forward and live-interactive modalities delivered through government national health systems and other government initiatives, commercial organizations for consumers, and non-profit/charitable organizations.  In addition, military use of ongoing teledermatology programs was also found in the literature review and included in this paper.

Figure 1. Map of sustained teledermatology programs and active pilot programs *4 pilot programs are no longer active [8,9-40].

17 countries performed feasibility or pilot studies, indicating the presence of technology and teledermatology infrastructure  which is presented below (Table 2). 

Table 2.  Summary of studies on teledermatology programs

Study

Country

Name and Location of Consulting Institution

Geographical Location(s) and/or Institution of Patient Recruitment

Modality and Relevant Technology

Comments

 

[41]

 

 

Argentina

 

Universidad Nacional de Tucuman

Ranchillos, Tucumán (province)

 

SAF using the Telemedicine in the Provincial System of Health (SIPROSA)

 

 

 

[42]

Belgium

Partnership between

Department of Dermatology, HôpitalUniversitaireErasme, UniversitéLibre de Bruxelles, Belgium and Dermatology Department of Kaolack Hospital in Senegal, West Africa;

Available to all internet users

Open source free website for telediagnosis, education, and information

Website titled “Black Skin Dermatology Online”, intended for use of consult for patients with dark pigmented skin.  Currently no telediagnosis on website

 

[43]

Chile

Consultation to a specialist in Santiago, Chile

Rural communities in Melipilla, Talagante, Isla de Maipo, Curacaví, and María Pinto, Chile

SAF using Ministry of Health (MINSAL) TD electronic platform

 

 

[44]

Denmark

Department of Dermatology, Roskilde Hospital, Roskilde, Denmark

4 home-care organizations in eastern Denmark

SAF using Plejenet, a web-based program created by Dansk Telemedicin

Specifically looked at wound care

[45]

Egypt

Department of Dermatology, Al Hussein University Hospital of Al-Azhar University in Cairo, Egypt

Cairo, Egypt; Al Hussein University Hospital of Al-Azhar University

SAF on a mobile phone with ClickDoc  (Click Diagnostics, Boston, MA) software and the telederm.org web-based platform

 

[46]

Finland

Department of Dermatology, Tampere University Hospital in Tampere, Finland

Ikaalinen, Finland; Primary Health Care Centre in Ikaalinen

Live-interactive videoconferencing

 

[47]

Germany

Clinic for Skin Diseases of the University of Greifswald, Greifswald, Germany

 

SAF on a smart phone and an online web-based portal

Information was transmitted directly via patients

[48]

Greece

Department of Dermatology and Plastic Surgery in the Athens General Hospital

 

SAF

 

[49]

Guatemala

Division of Dermatology, Albert Einstein College of Medicine, Bronx, NY, USA

Lake Atitlán, Guatemala; Rural clinics

SAF on a smart phone with an application developed by ClickMedix (mobile application/encrypted website)

medical students served as in-country proxies acting as liaisons between the in-country provider team and remote teledermatologist

 

[50]

Jordan

Prince Hamzah Hospital in Amman, Jordan

Mafraq Government Hospital and Queen Rania Hospital in Jordan

Live-interactive videoconferencing

 

[51]

Mexico

Department of Dermatology General Hospital of Mexico in Mexico City

Rural clinic in a small island

SAF with social media Facebook used as the web-based platform

 

[52]

Mongolia

Mongolian National University of Medical Sciences in Ulaanbaatar, Mongolia.

Districts Dhovd, Khuvgul, and Bulgan

SAF with mobile phone based, open source software platform data uploaded to Open MRS (electronic record system)

 

[53]

New Zealand

Department of Dermatology of Health Waikato in Hamilton

Taumarunui Hospital, Taupo Health Centre and the Ranolf Medical Centre

Live-interactive videoconferencing

in association with the UK Multicentre Teledermatology trials

[54]

Pakistan

Department of Pakistan Institute of Medical Sciences  in Islamabad, Pakistan

Islamabad, Pakistan; Department of Pakistan Institute of Medical Sciences  Institute of Dermatology King Edward Medical College Lahore

SAF using TelmedPak web-based platform

 

1-[39]

2- [55]

South Africa

1- Telemedicine Unit of the University of Transkei (UNITRA) in Umtata

2- Port Shepstone Hospital

1- Port St. John’s, South Africa

2- Durban, South Africa; Nelson R Mandela School of Medicine in

 

1- SAF using the iPath application network

2-  Live-interactive videoconferencing

 

1- [56]

2-[57]

Spain

 

1- Aragón, Spain

1-SAF web-based

2- ongoing

1- [58]

2- [59]

Sweden

1&2-Department of Dermatology at Sahlgrenska University Hospital

 

 

1-Referred by general practitioners in Gothernberg, Sweden 

2-unknown

 

 

SAF

1- mms messaging on a mobile phone

2- Tele-Dermis and iDoc24 mobile application

 

Of 131 countries searched in the study that did not have mention of a teledermatology program, a majority (80%) were in the bottom third in terms of population rank [60]

Teledermatology programs in developing countries were mainly delivered through non-profit/charitable humanitarian health networks with volunteer physicians and a simple, web based platform or email for communication between the consul tee and specialist (Table 3). 

Table 3. Humanitarian Telehealth Networks

Name of Network

Countries Served

Interface Used

Program Information

 

 

 

 

Swinfen Charitable Trust

Timor-Leste, Papua New Guinea, Cambodia, Sri Lanka, Nepal, Iraq, Afghanistan

Email

Second opinions delivered to doctors in developing nations via volunteer specialists around the world.  Consults are offered in 30 different specialties, with dermatology being one of the most common [61].

 

 

 

 

 

Telederm

Africa Telederm Project:

Swaziland, Lesotho, Botswana, Liberia, Eritrea, Malawi, Burkina Faso, Mozambique, Uganda, Kenya, Tanzania, Nigeria

Web based platform:

http://www.telederm.org

 

Request is sent with relevant clinical information, and up to 3 images are uploaded and sent to an expert.  Correspondence is private.  Images can also be sent to an online discussion forum[62].

 

 

 

iPath

Solomon islands, Lithuania, Switzerland

 

RAFT (Réseau en Afrique Francophone pour la Télémédecine):

Mauritania, Congo (Brazzaville), Benin, Burundi, Tunisia, Chad, Senegal, Rwanda, Mali, Niger, Burkina Faso, Madagascar, Cameroon, Cote D’Ivoire, Morocco, Algeria, Congo (Kinshasa)

 

 

Medecins Sans Frontiers:

South Sudan, Congo (Kinshasa), Ethiopia

Web based platform:

http://www.openclinical.org/os_iPath.html

Open access telemedicine platform hybrid web and email application for exchange of medical knowledge, distance consultations, group discussions and distance teaching in medicine[39]

 

Discussion

According to a 2011 WHO survey on global telemedicine, teledermatology is more established in high-income group countries, where the main challenges include legal issues with patient privacy and confidentiality, limited reimbursement for practitioners, and competing health system priorities. Developing countries are more likely to face larger barriers to implementation such as resource issues, high costs, underdeveloped infrastructure, and lack of technical expertise [1].  Therefore, teledermatology has been adopted more for use in the developed world where it is seen as a cost-effective way to increase access to care for patients who cannot travel or have inadequate insurance [63].  However, it has great potential to address challenges faced to those in the developing world that are deprived of even basic health care access. 

Although developing countries with a high burden of disease and limited resources or access to specialists can arguably benefit the most from teledermatology, many of these countries lack a reliable power supply and cannot afford any sophisticated software needed for a telemedicine exchange.  Physicians and government health policy makers in these regions that have very little to spend on healthcare per person may doubt the need for expensive teledermatology equipment when that money could go to much needed drugs for skin diseases.  Additionally, with the exception of leprosy and other infectious diseases that affect the skin, dermatologic conditions are given little importance in developing regions that suffer from major lethal health conditions such as malaria, tuberculosis, and HIV/AIDS [30]. 

Recognizing this dilemma faced by developing countries, humanitarian health networks have developed easy-to-use, open access platforms for underserved regions around the world.  The only requirements for participation in the teledermatology programs are access to the internet and a device to send and upload pictures (digital camera or phone).  Figure 2 shows a simple schematic of the information exchange in these health network teledermatology programs.

Figure 1. Map of sustained teledermatology programs and active pilot programs *4 pilot programs are no longer active [8,9-40].

These telehealth networks have been proven to be an efficient method of consultation.  A prospective review of email consultations between referring doctors and consulting specialists of Swinfen Charitable Trust operations showed a median time of 1.5 days from a referral to a definitive reply.  A similar study conducted on Telederm showed that 60% of requests were answered within one day, 35% within one week, and 4% in two weeks during the first two years of operation.  Because the only requirements for participation in the teledermatology programs are access to the internet and a device to send and upload pictures (digital camera or phone), these teledermatology programs have been able to penetrate many developing countries.  From 2000 to 2015, internet usage in underdeveloped regions such as Africa, Latin America, and the Middle East have exceptionally grown (Table 4) [64].  Additionally, access to mobile services in the developing world has outpaced the rate at which much of the population is gaining access to basic services such as banking, sanitation, and electricity [65].  With internet and mobile phone usage becoming increasingly available in all areas of the world, these telehealth networks have the potential to expand to more developing countries.

Table 4. World Internet Usage and Population Statistics

World Region

Internet Users 2000

Internet Users 2015

Growth 2000-2015

Africa

4,514,400

318,633,889

6,958.2 %

Latin America/Caribbean

18,068,919

322,422,164

1,684.4 %

Middle East

3,284,800

113,609,510

3,358.6 %

This review was done to provide a comprehensive overview of the prevalence and locations of teledermatology programs globally and has some limitations.  New teledermatology programs and pilot projects without published data could exist and were not included in this paper.  Articles published in different languages were not reviewed which could possibly explain the lack of teledermatology programs found in non-English speaking regions. Also, because a majority of the countries without a known teledermatology program were the least populous, it is possible that there is not a significant need for dermatologists in these areas.

Conclusion

In areas that do not have access to dermatologic care due to distance or simple manpower, teledermatology seems like an ideal solution to reach the underserved.  However, many factors such as cost, lack of access to modern communication, and underdeveloped infrastructure serve as major obstacles to its widespread use.   Teledermatology has been demonstrated to be feasible and diagnostically accurate in many different settings.  Although teledermatology programs are more prevalent in developed countries, non-profit/charitable humanitarian health networks have been able to serve many developing regions with a free and an easy-to-use interface. Future efforts need to focus on expanding the outreach of these existing humanitarian telehealth networks and/or simple, inexpensive technology and strategies to sustain programs in developed countries and developing countries that suffer from a high burden of disease with limited resources.  

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Editorial Information

Editor-in-Chief

Torello Lotti
University of Rome "G.Marconi" Rome

Article Type

Short Communication

Publication history

Received: September 06, 2015
Accepted: October 12, 2015
Published: October 15, 2015

Copyright

©2015 Gaffney R. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Citation

Gaffney R, Rao B (2015) Global teledermatology. Glob Dermatol, 2: DOI: 10.15761/GOD.1000156

Corresponding author

Rebecca Gaffney

Rebecca Gaffney, Rutgers Robert Wood Johnson Medical School Class, USA.

E-mail : rgg49@rwjms.rutgers.edu

Table 1. Dermatologist-population ratio in different regions of the world

USA

1: 30,000

UK

1: 200,000

Other European Countries

1: 50,000

Asia

1: 2000,000 (Urban)

 

1: 780,000 (rural)

Sub-Sahara countries

1: 1,000,000 (urban)

 

1: 5-50 million (rural)

Central/South America

1: 76,000 (urban)

 

1: 1-66 million (rural)

Table 2.  Summary of studies on teledermatology programs

Study

Country

Name and Location of Consulting Institution

Geographical Location(s) and/or Institution of Patient Recruitment

Modality and Relevant Technology

Comments

 

[41]

 

 

Argentina

 

Universidad Nacional de Tucuman

Ranchillos, Tucumán (province)

 

SAF using the Telemedicine in the Provincial System of Health (SIPROSA)

 

 

 

[42]

Belgium

Partnership between

Department of Dermatology, HôpitalUniversitaireErasme, UniversitéLibre de Bruxelles, Belgium and Dermatology Department of Kaolack Hospital in Senegal, West Africa;

Available to all internet users

Open source free website for telediagnosis, education, and information

Website titled “Black Skin Dermatology Online”, intended for use of consult for patients with dark pigmented skin.  Currently no telediagnosis on website

 

[43]

Chile

Consultation to a specialist in Santiago, Chile

Rural communities in Melipilla, Talagante, Isla de Maipo, Curacaví, and María Pinto, Chile

SAF using Ministry of Health (MINSAL) TD electronic platform

 

 

[44]

Denmark

Department of Dermatology, Roskilde Hospital, Roskilde, Denmark

4 home-care organizations in eastern Denmark

SAF using Plejenet, a web-based program created by Dansk Telemedicin

Specifically looked at wound care

[45]

Egypt

Department of Dermatology, Al Hussein University Hospital of Al-Azhar University in Cairo, Egypt

Cairo, Egypt; Al Hussein University Hospital of Al-Azhar University

SAF on a mobile phone with ClickDoc  (Click Diagnostics, Boston, MA) software and the telederm.org web-based platform

 

[46]

Finland

Department of Dermatology, Tampere University Hospital in Tampere, Finland

Ikaalinen, Finland; Primary Health Care Centre in Ikaalinen

Live-interactive videoconferencing

 

[47]

Germany

Clinic for Skin Diseases of the University of Greifswald, Greifswald, Germany

 

SAF on a smart phone and an online web-based portal

Information was transmitted directly via patients

[48]

Greece

Department of Dermatology and Plastic Surgery in the Athens General Hospital

 

SAF

 

[49]

Guatemala

Division of Dermatology, Albert Einstein College of Medicine, Bronx, NY, USA

Lake Atitlán, Guatemala; Rural clinics

SAF on a smart phone with an application developed by ClickMedix (mobile application/encrypted website)

medical students served as in-country proxies acting as liaisons between the in-country provider team and remote teledermatologist

 

[50]

Jordan

Prince Hamzah Hospital in Amman, Jordan

Mafraq Government Hospital and Queen Rania Hospital in Jordan

Live-interactive videoconferencing

 

[51]

Mexico

Department of Dermatology General Hospital of Mexico in Mexico City

Rural clinic in a small island

SAF with social media Facebook used as the web-based platform

 

[52]

Mongolia

Mongolian National University of Medical Sciences in Ulaanbaatar, Mongolia.

Districts Dhovd, Khuvgul, and Bulgan

SAF with mobile phone based, open source software platform data uploaded to Open MRS (electronic record system)

 

[53]

New Zealand

Department of Dermatology of Health Waikato in Hamilton

Taumarunui Hospital, Taupo Health Centre and the Ranolf Medical Centre

Live-interactive videoconferencing

in association with the UK Multicentre Teledermatology trials

[54]

Pakistan

Department of Pakistan Institute of Medical Sciences  in Islamabad, Pakistan

Islamabad, Pakistan; Department of Pakistan Institute of Medical Sciences  Institute of Dermatology King Edward Medical College Lahore

SAF using TelmedPak web-based platform

 

1-[39]

2- [55]

South Africa

1- Telemedicine Unit of the University of Transkei (UNITRA) in Umtata

2- Port Shepstone Hospital

1- Port St. John’s, South Africa

2- Durban, South Africa; Nelson R Mandela School of Medicine in

 

1- SAF using the iPath application network

2-  Live-interactive videoconferencing

 

1- [56]

2-[57]

Spain

 

1- Aragón, Spain

1-SAF web-based

2- ongoing

1- [58]

2- [59]

Sweden

1&2-Department of Dermatology at Sahlgrenska University Hospital

 

 

1-Referred by general practitioners in Gothernberg, Sweden 

2-unknown

 

 

SAF

1- mms messaging on a mobile phone

2- Tele-Dermis and iDoc24 mobile application

 

Table 3. Humanitarian Telehealth Networks

Name of Network

Countries Served

Interface Used

Program Information

 

 

 

 

Swinfen Charitable Trust

Timor-Leste, Papua New Guinea, Cambodia, Sri Lanka, Nepal, Iraq, Afghanistan

Email

Second opinions delivered to doctors in developing nations via volunteer specialists around the world.  Consults are offered in 30 different specialties, with dermatology being one of the most common [61].

 

 

 

 

 

Telederm

Africa Telederm Project:

Swaziland, Lesotho, Botswana, Liberia, Eritrea, Malawi, Burkina Faso, Mozambique, Uganda, Kenya, Tanzania, Nigeria

Web based platform:

http://www.telederm.org

 

Request is sent with relevant clinical information, and up to 3 images are uploaded and sent to an expert.  Correspondence is private.  Images can also be sent to an online discussion forum[62].

 

 

 

iPath

Solomon islands, Lithuania, Switzerland

 

RAFT (Réseau en Afrique Francophone pour la Télémédecine):

Mauritania, Congo (Brazzaville), Benin, Burundi, Tunisia, Chad, Senegal, Rwanda, Mali, Niger, Burkina Faso, Madagascar, Cameroon, Cote D’Ivoire, Morocco, Algeria, Congo (Kinshasa)

 

 

Medecins Sans Frontiers:

South Sudan, Congo (Kinshasa), Ethiopia

Web based platform:

http://www.openclinical.org/os_iPath.html

Open access telemedicine platform hybrid web and email application for exchange of medical knowledge, distance consultations, group discussions and distance teaching in medicine[39]

 

Table 4. World Internet Usage and Population Statistics

World Region

Internet Users 2000

Internet Users 2015

Growth 2000-2015

Africa

4,514,400

318,633,889

6,958.2 %

Latin America/Caribbean

18,068,919

322,422,164

1,684.4 %

Middle East

3,284,800

113,609,510

3,358.6 %

Figure 1. Map of sustained teledermatology programs and active pilot programs *4 pilot programs are no longer active [8,9-40].

Figure 2. Flow of Information for Swinfen Charitable Trust, Telederm, and iPath Telehealth Networks