title: Lessons learned after a three-year store and forward teledermatology experience using internet: Strengths and limitations.
abstract: OBJECTIVE
  This paper presents a three-year teledermatology evaluation experience. The aim is to explain the methodology followed, present the evaluation results, discuss critically the issues that emerged during the experience and report the main lessons learned.
  
  
  METHODS
  A complete design and evaluation methodology was conducted to fully address significant issues arising from other previous teledermatology experiences. First, system-design requirements and image quality issues were studied. Then, a detailed clinical concordance study was undertaken to determine the accuracy of diagnoses made using teledermatology in order to assess different dermatological clinics. Finally, an impact study on the health system was performed. Furthermore, clinical, technical, social and alignment outcomes were analyzed during the study and at the end of it, in order to understand how emerging factors affected the final setup of the teledermatology system.
  
  
  RESULTS
  The most important results reported in this study can be summarized as follows. (1) A complete web-based environment for teledermatology support was developed as a result of a dynamic evaluation process with clinical personnel. (2) A total of 120 teleconsultations (82 pediatric and 28 adult) were made during the clinical concordance study. Concordance analysis was carried out for each dermatological disease group. High concordance rates were found in pediatrics for inflammatory dermatoses (76%) and also for adults (75%) with infections and infestations. (3) Physicians were satisfied with the teledermatology system but the time dedicated to consultation in primary care was a limiting factor (19min for each teleconsultation). (4) An extensive discussion about the successful and the limiting aspects of the teledermatology experience revealed the reasons behind the final decision not to proceed with its implementation. It was considered not to be aligned with Health Care Organization (HCO) strategy and consequently did not achieve high-level support for its long-term implementation.
  
  
  CONCLUSIONS
  A high degree of diagnostic accuracy both for pediatric and adult consultations was achieved using the teledermatology system with affordable technical requirements. Its usefulness for filtering dermatological referrals was also demonstrated in the study. Nevertheless, other factors such as the reorganization required for the physicians' time schedule, remuneration issues, absence of EHR (electronic health record) integration and lack of interaction with the HCO were important limiting factors. This led to the conclusion that under the evaluation conditions long-term set-up was not possible. It was also concluded that HCO participation would have been essential for both the evaluation study and the long-term set-up of the system.
authors.affiliation: Communications Technologies Group-GTC, Aragón Institute of Engineering Research I3A, University of Zaragoza, Spain. nelia.lasierra@unizar.es
authors.forename: N
authors.initials: N
authors.lastname: Lasierra
authors.forename: A
authors.initials: A
authors.lastname: Alesanco
authors.forename: Y
authors.initials: Y
authors.lastname: Gilaberte
authors.forename: R
authors.initials: R
authors.lastname: Magallón
authors.forename: J
authors.initials: J
authors.lastname: García
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002648:Child; D002675:Child, Preschool; D003880:Dermatology; D005260:Female; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D015588:Observer Variation; D019114:Remote Consultation; D060926:Remuneration; D015203:Reproducibility of Results; D012871:Skin Diseases / Q000175:diagnosis*; D017216:Telemedicine; D055815:Young Adult