36 CHAPTER 2 voluntary service. Teledermatology programs were reimbursed by private payers (N=25, 69%), by self-payers (N=22, 61%), Medicaid (N=20, 56%), Medicare (N=19, 53%), and by HMO (N=17, 47%). Thirty-nine states in the USA receive some reimbursement for telehealth services provided by Medicaid [24]. Reimbursement of other countries and business models were not found in our literature search. In the Netherlands, teledermatology is fully reimbursed and integrated into the national healthcare system. Teledermatology was introduced during the first 5 years of this century in small pilots together with innovating dermatologists and general practitioners on a regional basis as a part of clinical research, thus building clinical evidence and broad basic support among future users. From 2005, health institutions (e.g., Ksyos TeleMedical Center) that solely focused on providing telemedicine and eHealth services, actively implemented teledermatology in the existing health infrastructure. Pivotal factors in the successful implementation have been the focus on change management among and continuous support of future users in the field. GPs were approached to start with teledermatology when the local dermatologists were already on board and could act as local drivers of this new service. Health workers have been trained and supported during the process of implementation. The health institutions providing teledermatology took full responsibility for the entire process including medical responsibility. They contracted medical specialists and general practitioners as well as health insurers and were responsible for quality control. These parties provided safe and user-friendly transmural electronic health records that facilitated the process of teledermatology. Finally, from 2005, the health insurers have reimbursed teledermatology, leading to further increase of its use. This has led to a steady increase in general practitioners using tele consultation services in various fields (e.g., dermatology, ophthalmology, cardiology, and mental health) from 120 in 2005 to an estimated 5500 in 2015 (60% of all GPs in the Netherlands). Integration in national healthcare systems In 2009, the eHealth survey of the World Health Organization (WHO) showed that a teledermatology service was established in only 16% of the 114 responding countries [25]. Less is published about the integration of teledermatology in national healthcare systems. In the beginning of 2012, 37 teledermatology programs were active in the USA [20]. Reimbursement is often an obstacle for the implementation of telemedicine into (national) health care systems [26]. The Veterans Health Administration (VHA) has designed one of the largest teledermatology programs in the USA [21]. Furthermore, teledermatology has been broadly integrated into the Dutch healthcare system since 2006 and is fully reimbursed. In 2014, more than 12% of the GP visits in the Netherlands was related to dermatological care [27], and in total 27.2 per 1000 patients in GP practice were referred to a dermatologist [27]. Ksyos TeleMedical Center [28] provides specialized tele-medical care in the Netherlands. In 2015, Ksyos TeleMedical Center provided 14,900 teledermatology (store-and-forward) consultations in which 3421 GPs and 247 dermatologists were involved. Since the introduction of teledermatology in 2006, a total
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