title: Evaluation of a tertiary teledermatology service between peripheral and academic dermatologists in the Netherlands.
abstract: BACKGROUND
  Tertiary teledermatology (TTD)-secondary-care to tertiary-care teleconsultation-is applied rarely compared with the frequently applied secondary teledermatology (primary to secondary care). The objective of this study was to determine the effect of TTD on referrals from peripheral dermatologists to the tertiary center and to evaluate acceptance of TTD.
  
  
  METHODS
  From May 2010 to May 2012, 39 dermatologists could send in teleconsultations to one of two tertiary centers. Physical referrals to the tertiary centers prevented by TTD were calculated based on questions before and after TTD. The acceptance of the TTD system was evaluated through questionnaires, a focus group meeting, and personal interviews.
  
  
  RESULTS
  Eighty-five teleconsultations were sent by 13 peripheral dermatologists from nine care institutions and answered by 8 tertiary dermatologists. Of the patients, 62% (n=53) would have been referred physically to the tertiary center if teledermatology were not available. In this group, teledermatology prevented 81% (n=43) of physical referrals. Dermatologists indicated that TTD had important advantages such as fast response time, formalized records, and data and privacy security. However, the current work process using telephone and e-mail was preferred because of its ease of use and direct personal network. The following conditions that could lead to successful implementation were indicated: (1) a national TTD system including all dermatologists indexed according their subspecialty, (2) ability to send the TTD consultation to a dermatologist personally, (3) ability to discuss a case with multiple dermatologists, (4) connections to electronic health records, and (5) change in policies of tertiary centers or health insurers, where they would stimulate the use of TTD consultation for all referrals and questions.
  
  
  CONCLUSIONS
  Although quantitative results indicate that TTD can be used to improve triage between secondary and tertiary centers and dermatologists perceived advantages of TTD, the motivation to use TTD in this setting was lacking as current work processes were easier to use.
authors.affiliation: 1 Department of Dermatology, Academic Medical Centre, University of Amsterdam , Amsterdam, The Netherlands .
authors.forename: Job P
authors.initials: JP
authors.lastname: van der Heijden
authors.forename: Nicolette F
authors.initials: NF
authors.lastname: de Keizer
authors.forename: Leonard
authors.initials: L
authors.lastname: Witkamp
authors.forename: Phyllis I
authors.initials: PI
authors.lastname: Spuls
mesh_terms: D003880:Dermatology / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D009426:Netherlands; D012017:Referral and Consultation; D019114:Remote Consultation; D062606:Tertiary Care Centers