37 TWO DECADES OF TELEDERMATOLOGY of 130,531 teledermatology consultations have been performed by Ksyos TeleMedical Center in the Netherlands. Preconditions and requirements for implementation of teledermatology Perceived barriers and incentives for implementation of teledermatology services differ for primary care physicians and dermatologists and should be taken into account during the implementation. Equipment costs and management and staff training are implementation barriers as perceived by primary care physicians while medical legal liability, diagnostic reliability, and patient follow-up are barriers for academic dermatologists [29,30]. Both groups are concerned about the financial reimbursement of teledermatology [29,30]. In the Netherlands, lack of reimbursement was not an issue during the initial introduction among innovators. However, for the large-scale implementation that has happened in the Netherlands, reimbursement of dermatologists as well as general practitioners has been pivotal. Various preconditions and requirements should be considered while implementing a teledermatology program. First of all, an important precondition for teledermatology is assignment of persons responsible for the service as a whole, by extension for (in) correct diagnosing and prescribing the associated treatment, and reflecting on the legal risks [31,32]. Secondly, there are some legal and ethical issues. If images of patients are sent to the dermatologists, instead of the patient itself, a physical physician-patient relationship does not exist according to regulations in some countries [32]. Each country has its own laws and regulations that influence implementation. For example, some states in the USA impose restrictions in providing teledermatology to other states in which the physician is not working and licensed, and in the Netherlands teledermatology between patient and dermatologist is only allowed when it concerns a follow-up consultation and the physician-patient relationship has been established in the first face-to-face consultation. This implied that in order to implement teledermatology in the Netherlands, both general practitioner and dermatologist had to be contracted by the same health institution. Doing so, the patient is seen at least once physically by a health worker, in this case the general practitioner, contracted by the health institution. This is mandatory in the Netherlands in order to be able to receive reimbursement from the health care insurers. Thirdly, security is an essential requirement for teledermatology implementation. Requirements for a secure teledermatology system described in the literature are privacy, availability, authentication, authorization, storage and network security, data encryption, confidentiality, and non-repudiation [9,33]. Data transmission should be reliable and the system should be continuously available, easily accessible and there should be a reliable and secure computer connection. Furthermore, the technical equipment used for taking the pictures and sending the images should operate properly. Patients and health 2
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