15 GENERAL INTRODUCTION Teledermatology The first type of store-and-forward digital dermatology consultation that GPs can perform through the telemedicine organization is regular teledermatology (Figure 1.3). To start a teledermatology consultation, GPs directly log in through a single sign-on from their GP Information System (Dutch: Huisarts Informatiesysteem (HIS)) in the telemedicine platform or they sign in on the telemedicine organization’s website. The GP uses a digital camera or ubiquitous smartphone or tablet to take detailed and overview photographs of the patient’s skin lesion. A maximum of four obtained images can be uploaded to a standardized consultation request after oral consent from the patient. The GP completes the consultation request with an anamnesis (for example, additional patient information, patient medication, prehistory of skin cancer, etc.), optionally enters a primary (differential) diagnosis and selects a TD for assessment. After sending the consultation to a TD for assessment, for each consultation the GP is asked through an embedded evaluation question on the platform, whether the GP would have referred the patient without the availability of teledermatology (Box 1.1). Within two working days, the TD assesses the images of the skin lesion in the consultation request, provides a mandatory primary diagnosis and advice to a GP. If the TD cannot assess the skin lesion based on the pictures added, there is an option for the TD to choose “no diagnosis,” “non-assessable,” or “no abnormalities.” Both GP and TD diagnoses in the teledermatology platform are automatically coded according to the International Classification of Diseases, 10th revision (ICD-10) [54]. This worldwide used ICD-10 classification contributes to a consistent way of reporting and monitoring diseases and health-related conditions. Since July 2015, Dutch specialized care organizations are obliged by the Dutch Healthcare Authority (Dutch: Nederlandse Zorgautoriteit, NZa) to register diagnoses in compliance with such an ICD-10 code. This classification standard is controlled by the World Health Organization and facilitates, for example, data analysis on provided diagnoses over time. In this thesis, we compared the GPs and TDs diagnoses with each other and analyzed the TD diagnoses based on the derived ICD-10 codes. Furthermore, we used the ICD-10 codes to map the TD diagnoses into three diagnosis groups (benign, premalignant, and malignant). The TD diagnoses were used as a diagnosis measure in our studies as not all TD diagnoses were face-to-face or histopathologically confirmed. In addition, face-to-face or histopathological diagnoses determined after teledermatology were out of our study scope as these were not registered into the digital dermatology platform and interoperability and privacy restrictions of data limited the exchange of this data between the electronic patient records of the dermatologists and the teledermatology platform. In addition to providing a diagnosis via the digital dermatology platform, the TD responds through an evaluation question whether a physical referral to a dermatologist is necessary (Box 1.1). The GP receives the TD response in the teledermatology platform and (if preferred by the GP, automatically) in the GP’s HIS. Afterwards, the GP completes three evaluation questions in the teledermatology platform (Box 1.1). 1
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