191 GENERAL DISCUSSION In contrast to this passive patient role during teledermatology and teledermoscopy, the patient plays an active role in the dermatology home consultation care path that took off during the COVID-19 pandemic. Because patients are directly and actively involved in the dermatology home consultation process and could complete an online questionnaire immediately after the consultation, we expect that a standardized and validated questionnaire for dermatology home consultation leads to higher patient questionnaire responses. Therefore, a next step is to develop and validate a new questionnaire asking patients about dermatology home consultation and to assess patients’ satisfaction with the service. In addition, we recommend delving further into the quality of the images taken by patients in the dermatology home consultation care path. Our study in Chapter 7 showed that most GPs had positive experiences with dermatology home consultation but experienced that not all photographs taken by the patients were of sufficient quality. Other studies in the literature also showed that photographs taken by patients and immediately sent to the dermatologist (instead of the GP) were of insufficient quality [34,35]. In contrast to most GPs, patients are novel users of digital dermatology services, receive no education and cannot be trained to take photographs of their skin. Despite these issues, most patients have smartphones [36], which are used to take images themselves in their own time, and have time to retake images. Future studies should investigate whether patients can engage the dermatology home consultation service on their own and whether feedback and step-by-step, understandable, and straightforward guidance on the platform or (video)instructions are sufficient to support patients in taking proper photographs of their skin conditions [27,37]. Intensified use of digital dermatology in general practice or at the patient home is only effective if the GP and the patient use these services properly. This requires user-friendly interfaces of the applications and demands specific attention for patients with low digital skills and for low health literate patients [38]. Future studies should investigate whether dermatology home consultation is feasible for those under-resourced patients (for example elderly/fragile patients, patients with low social economic classes, low (technical) literate patients, etc.) who might lack proper equipment or digital skills and which extra assistance they need to perform dermatology home consultation adequately. Continuous quality cycle The Dutch Healthcare Quality, Complaints and Disputes Act (Dutch: Wet kwaliteit, klachten en geschillen zorg (Wkkgz)) obliges healthcare organizations and individual health care providers to continuously monitor, control and improve their provided quality of care [39]. This means that for sustained growth and to guarantee the quality of the entire (digital) dermatology flow, telemedicine organizations, patients, GPs, and dermatologists must continuously and proactively evaluate the care path flow. Validated questionnaires, such as the developed SAF-TSUQ instrument (Chapter 6) measuring GPs’ and TDs’ satisfaction with store-and-forward telemedicine organizations, can be used for this continuous quality improvement cycle. The SAF-TSUQ focuses on healthcare providers’ satisfaction and 8
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