184 CHAPTER 8 with major healthcare challenges such as increasing costs of healthcare and welfare and the shortages of personnel working in healthcare [2]. One of the aims established in the IZA is to reduce the workload of healthcare providers and at the same time to maintain high-quality healthcare that is accessible and affordable. Furthermore, the IZA describes that Dutch healthcare should transform to hybrid care, and that investigation is necessary to determine which care paths are suitable for digital and hybrid care. Moreover, one of the spearheads of Dutch health insurers is to realize hybrid general care practices while preventing and improving referrals to secondary care [3]. This thesis showed that teledermatology and teledermoscopy are examples of laborsaving innovations that are extremely suitable for digital and hybrid care, support GPs in reorganizing their work and result in fewer patient referrals to the dermatologist. In essence, digital dermatology services offer the right low-complex (diagnostic) care in the right place at the right time with the right expertise and motivate GPs and dermatologists in the performance of their duties. Thus, digital dermatology services connect seamlessly with the IZA starting point to realize appropriate hybrid care: perform care yourself if possible, perform care at home if possible, perform care digitally if possible, and visit the hospital only for specialized care [2]. That digital care can actually be realized in GP practice is also shown in the number of dermatology, somnology, mental health, cardiology, and pulmonology consultations yearly conducted via telemedicine platforms, such as Ksyos [4]. Education and training of GPs The research presented in this thesis showed that education and training of GPs to enhance their dermatology knowledge and skills on how to use photography devices are substantial aspects for efficient teledermatology and teledermoscopy use. For example, Chapter 3 and 5 highlighted that GPs frequently changed their initial referral decision after a teledermoscopy consultation; there is thus room for GPs to expand their knowledge regarding when to (not) refer a patient to a dermatologist. Teledermoscopy can therefore act as a tool for GPs to fine-tune their decisions as gatekeepers to secondary care, thereby reducing the need for physical referrals of patients. Furthermore, Chapter 5 demonstrated that without the availability of digital dermatology, GPs would refer patients with benign lesions to the dermatologist and would have missed referrals of patients with skin lesions suspected of malignancy. In some cases, it is still necessary to refer patients with benign skin lesions to the dermatologist, for example for an atypical nevus on the face for which the expertise of the dermatologist for excision is consulted, but for most low-complex benign skin lesions a physical referral can be prevented. GPs have room to improve their dermatology knowledge because dermatology education has been underrepresented in the medical and GP training curriculum [5]. Besides that, the use of digital health applications and taking (dermoscopic) photographs have also been inadequately integrated into the Dutch medicine and GP training curricula [6,7]. GP trainees obtained this dermatological and digital knowledge from their GP supervisors during post graduate
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