Some geographical locations have relatively few specialist medical practices. Getting an appointment with a specialist if you live in such areas might mean a long wait or a long journey. A study being carried out at the University of Tübingen is looking to improve this situation: the TeleDerm project involves dermatologists using telemedicine to assess skin disorders from images taken by GPs. Results are available within two days. The service will initially only be available to AOK* patients in selected regions, but if it proves successful, it will be extended to other insurance companies and regions.
Patients who need to consult a specialist for an expert opinion are likely to have to wait a long time and travel long distances for an appointment. Telemedicine offers a potential improvement to this situation through the electronic transmission of patient data and findings between doctors. This helps reduce waiting time and travel distance to access specialist help. The expectation is that in the future many patients will simply see their GP, and save themselves a trip to a specialist.
Some regions are particularly short of dermatologists, which can be a real problem since skin diseases have become relatively common. That said, GPs are available as an effective first point of contact for people suffering from skin diseases. “Statistically speaking, 7 to 10 percent of all patients with skin problems see their family doctors, who can actually treat nine out of ten patients. All other patients need to be referred to a specialist,” says Andreas Polanc, a scientist at the Institute for General Practice and Interprofessional Care at the University Hospital in Tübingen.
Around two years ago, doctors from Tübingen University Hospital organised a meeting to provide information about telemedicine services and find out whether doctors needed telemedicine services for skin diseases. “We were aware of the excellent results in the Netherlands where telemedicine services have been available for many years. So we decided to invite the dermatologist and founder of KSYOS (the largest telemedicine centre in the Netherlands), a number of physicians and an AOK representative to a meeting to present our idea on teledermatology,” says Polanc. “It immediately fell on fertile ground, and we decided to set up the TeleDerm project. This project is aimed at alleviating the shortage of dermatologists and using teleconsultation services to ensure the most efficient treatment of patients with skin diseases close to where they live.”
A consortium was formed shortly after the meeting. It is coordinated by the Institute for General Practice and Interprofessional Care in Tübingen led by Prof. Dr. Stefanie Joos. In addition to AOK Baden-Württemberg, the consortium also includes KSYOS and several university institutes. The TeleDerm project commenced in 2017. It has been given two million euros in funding by the German Federal Innovation Fund. Since the end of 2017, the medical practices involved in the project have been equipped with the necessary technology. In addition, training and information has been provided on how participants can contribute data to the study. "We expect this run-in phase to be completed by June 2018," says Polanc, who is the coordinator of TeleDerm. The official intervention phase will commence on July 1st 2018 and continue until 30th June 2019. During this period, adult patients who have given written consent to participate in the AOK Baden-Württemberg GP model will be able to access telemedical treatment in 50 GP practices in the administrative districts of Calw, Böblingen, Zollern-Alb and Rottweil.
A teledermatological consultation involves a standard visit to the family doctor, who uses a dermatoscope to take pictures of the affected skin area, and subsequently transmits the images to a specialist. "The dermatoscope looks like a very thick marker pen," explains the Tübingen project coordinator. "This ‘pen’ is simply held over the skin to record a highly resolved image, which is subsequently securely transferred to the server in the Netherlands using a practice management system along with the patient's medical history, age, pseudonym and gender.”
A randomised procedure distributes the patient data to one of the participating dermatologists. This random selection ensures data quality. Once the data has been sent to the dermatologist, he or she receives an email notification and can start the assessment. The dermatologist then gives the GP treatment information for the skin problem and decides whether the patient needs to see a specialist in person. The software comes with a feedback loop to enable participating doctors to communicate with each other if necessary. The goal is to make the results available to the GPs within just two days. “IT remains a particular challenge for teleconsultations, especially as there are around 170 different practice management systems in Germany,” says Polanc. “Medical informatics specialists from the Reutlingen University of Applied Sciences have developed specific interface solutions to ensure that patient data is secure. This is pivotal for the implementation of telecommunication services in standard patient care.”
The information collected in teleconsultations is assessed qualitatively as well as quantitatively. For example, patients, doctors and other medical staff are asked how they implement teledermatology services in their day-to-day work, feasibility, problems and whether they are happy with the service. Anonymised secondary AOK data and process data such as the number of referrals, queries and processing time are also analysed. The LMU in Munich will carry out a cost evaluation of the project.
Polanc points out that, in principle, all dermatological disorders can be treated, but it is down to GPs to assess whether a teleconsultation is necessary. Patients themselves do not need any special technological knowledge or equipment. “The entire teleconsultation service is carried out from the GP’s practice,” says Polanc. “The risk that the patients might access too much information outside of a proper medical context before consulting their GP could lead to incorrect preconceptions. Therefore, the family doctor decides whether a teleconsultation is necessary – thus acting as a kind of filter. Otherwise, the patients would probably use it more frequently. They will of course be given comprehensive information sheets and will only take part in teleconsultations if they wish to do so.” If the results from TeleDerm are positive, teleconsultation services will be provided to as many patients as possible.
On the international level, the experience with telemedicine has been generally quite good. According to a WHO1 study, special programmes already exist in over 50% of member states. In countries where teleconsultation services have been offered for some time, acceptance is generally quite high, and the number of referrals to specialists and healthcare costs have dropped significantly. "Of course, both doctors and patients tend to be rather sceptical at first," says Polanc. "But we want this project to show that such scepticism is unfounded, and the time savings for everyone involved are enormous." In principle, teleconsultations could be extended to other disorders as well, including eye, ear, nose and ear diseases as well as lung and heart diseases. "But for the time being, we need to wait for the results and see how the whole system works," says Polanc. "Interoperability is a huge challenge for us, as the project involves so many different players. But that is what makes it so interesting.”
*AOK: Germany’s largest SHI healthcare fund
1 Global diffusion of eHealth: Making universal health coverage achievable. Report of the third global survey on eHealth. World Health Organization 2016.