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Are recommendations from remote dermatologists reliable?

By Andrew M. Seaman

NEW YORK (Reuters Health) - Offsite doctors may be able to reliably evaluate hospitalized patients with possible skin conditions based on photographs and general health information, says a new study.

Researchers found that dermatologists who evaluated hospitalized patients remotely using pictures and health information often reached the same conclusions as a doctor who examined the patients in person.

Using so-called teledermatology to identify patients who need additional care or screening may improve access to dermatology services in rural areas, according to the study's senior author.

"Across the country and the world there are places that have limited or no dermatology support," Dr. Misha Rosenbach told Reuters Health. "There are a lot of issues with having the right doctors in the right place to care for patients."

Rosenbach is director of the inpatient dermatology service at Penn Medicine in Philadelphia.

He and his colleagues write in JAMA Dermatology that many hospitals don't have dermatologists available for patient consultations. By using teledermatology, doctors at other hospitals or in private practice can look at pictures and make recommendations.

"There is a real dermatology workforce shortage, especially in rural areas," Dr. Lindy P. Fox told Reuters Health in an email.

"Teledermatology is a viable way to deliver care to those who do not have direct access to dermatologists as it allows dermatologic care to be delivered in a timely manner to patients who might have long wait times to see a dermatologist or have to travel long distances to see a dermatologist," she added.

Fox, a dermatologist at the University of California, San Francisco, wrote an editorial accompanying the new study.

To see how reliable offsite evaluations are, the researchers compared the recommendations of a doctor who evaluated 50 patients in person to the recommendations of two doctors who evaluated the patients via teledermatology.

All the patients were over 18 years old and inpatients at the Hospital of the University of Pennsylvania in Philadelphia from September 2012 through April 2013.

Overall, they found that if the in-person doctor suggested the patient have a consultation that same day, the offsite doctors agreed 90 percent of the time.

When doctors did disagree, the researchers write, it was usually over how to manage the condition while still agreeing with each other on the diagnosis.

Also, when the in-person doctor recommended samples of the patients' skin be taken for testing, the offsite doctors agreed 95 percent of the time.

"Our findings suggest that teledermatology is reliable for the initial triage of inpatient dermatologic consultations," the researchers write.

"I do think there is some hope that using teledermatology can really expand access to get patients dermatology help when they need it," Rosenbach said.

He said that patients needing a consultation with a dermatologist in a hospital are often complex and may have life-threatening conditions, such as Stevens-Johnson syndrome, a severe reaction to infection or medication that includes a painful rash.

"One of the unique perspectives of this study is that it addresses improving access to dermatologists in the hospital setting, a place where dermatologists traditionally do not spend the majority of their practice time," Fox wrote.

In the past, researchers have mostly evaluated the use of teledermatology in the form of individuals using mobile phone cameras to transmit pictures of suspicious moles or lesions to dermatologists.

In another report published in JAMA Dermatology, a group of researchers builds on their previous research to see how high-risk patients select which moles or lesions to photograph.

Led by Monika Janda at the Queensland University of Technology in Brisbane, Australia, the researchers report that people tended to photograph lesions located on their arms, face, legs, shoulder and back. They avoided their "sexually sensitive" and hard-to-see areas.

They conclude more research is needed and suggest that people who get help with self-evaluations and who increase the number of self-evaluations they perform on themselves may miss fewer moles and lesions.

In an editorial published in the same journal, Courtney Rubin and Dr. Carrie Kovarik of the University of Pennsylvania in Philadelphia say that teledermatology is promising but patients should be aware of its limitations.

"The patient must understand the limitations of private provider-to-patient consultation services: follow-up and diagnostic testing such as skin biopsy may not be possible, and the accuracy of the diagnosis is limited by the information provided by the patient and the quality of the photographs," they write.

SOURCE: http://bit.ly/1dowP1B, http://bit.ly/1gAegpK, http://bit.ly/MgsPG0 and http://bit.ly/1czEPIJ JAMA Dermatology, online February 12, 2014.

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