9 GENERAL INTRODUCTION systematic reviews show that patients and care providers are satisfied with teledermatology services [26,27]. However, due to the heterogeneity between studies in the literature, different statements are made regarding the diagnostic reliability and referral management accuracy with these services compared to traditional in-person dermatology consultation [28,29]. Teledermatology has been aided by the evolution of consumer digital cameras and mobile phones as photo-capturing devices for GPs and by the emergence of the Internet. The expectations were that the use of smartphones in teledermatology services for patients and GPs would become increasingly integrated into healthcare like smartphones became indispensable in everyday life [30]. Literature nevertheless shows that several teledermatology implementation barriers (for example reimbursement issues, communication challenges, the lack of clinical information such as missing patient history or images in the consultation, and technological impediments) hampered the frequent use of teledermatology in daily practice worldwide before the COVID-19 pandemic [22,24,31]. The pandemic, on the other hand, stimulated the relaxations around laws and regulations and triggered the extension of reimbursement for teledermatology consultations [24,31]. As a result, the sudden need for digital care during the pandemic accelerated the implementation and adoption of several teledermatology services as healthcare solutions around the world [24,31,32]. In contrast to other countries, the Netherlands was the first country where teledermatology services had already been integrated into Dutch GP practices nationally and reimbursed by health insurance companies before the pandemic (since 2006) [33]. Results of a largescale implementation of teledermatology in Dutch daily GP practices in 2011 already showed that teledermatology reduces the number of physical referrals and delivers efficient and affordable care [33]. Despite these proven successes and expectations regarding the potential of teledermatology to address current healthcare challenges, the number of deployed digital dermatology consultations stabilized before the pandemic and the growth of this promising service stopped in the Netherlands [34]. Figure 1.1 shows the number of digital dermatology consultations registered by a telemedicine organization in the Netherlands delivering teledermatology services. One of the causes of this stagnation in usage may be an improvement in dermatological knowledge GPs acquire and their learning curve of diagnosing skin lesions after frequent use of these services [33,35]. This learning curve and gained expertise in dermatology might have reduced the need for GPs to utilize teledermatology for subsequent patients with similar lesions. Moreover, certain obstacles could hamper the upward trend in the use of digital dermatology consultations. It is unknown how GPs experienced the existing digital dermatology services during the COVID-19 pandemic and which facilitators and barriers GPs encountered in the use of these services. Therefore, this thesis investigates the status of digital dermatology in Dutch GP practices and the use of the service during the COVID-19 pandemic. More specifically, the added value of digital dermatology consultation for GPs, the challenges 1
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