94 CHAPTER 5 number of (pre)malignant and benign diagnoses for which teledermoscopy was applied by the GPs. It is possible that TDs were unable to provide a diagnosis because the GPs provided insufficient patient information in the teledermoscopy consultation [20]. Furthermore, overview or dermoscopic photos taken by the GP may have been lacking in the teledermoscopy consultation or may have been of insufficient quality [6,10]. The Ksyos teledermoscopy system does not validate whether a dermoscopic photo of the skin lesion is available at all and if it is, whether the photo quality is sufficient. GPs can only retake the photos if they receive direct feedback from the TD and if the patient is present at the GP practice. In the future, an algorithm could be created into the teledermoscopy system that assesses the photo quality and provides real-time, direct feedback to the GP if improvements are necessary. Showing instructions in the Ksyos teledermoscopy system (e.g., image quality checklist, guidelines on taking dermoscopic photos) could support GPs in filling in the teledermoscopy consultation completely and ensure photos of sufficient quality and correct type (overview, detailed, dermoscopic) [21,22]. The second limitation of our study is that the GPs were not obliged to fill in the selfadministered questions regarding their referral decisions; thus, these self-administered questions were not always filled in. For these teledermoscopy consultations, we could not compare the GP referral decision before and after the teledermoscopy consultation. In addition, we do not know if the GP interpreted these questions regarding their referral decision as originally intended in the teledermoscopy system. The reasons why GPs decided not to physically refer patients with a TD-diagnosed (pre)malignant skin lesion are still unknown. Additionally, clinical follow-up data on these patients are lacking. The Dutch guideline for suspicious skin abnormalities recommends that GPs refer malignant skin lesions to the dermatologist [23]. We know from dermatology experience that it is possible for GPs to deviate from this guideline after contact with a dermatologist; for example, for elderly patients, if the GP is experienced in excision of lesions, if the excision has already been performed, or for superficial lesions that do not require invasive treatment. For premalignant diagnoses, TDs also have an important advisory role for GPs on how to treat patients. Referral of premalignant lesions is dependent on the condition (location, evolvement, etc.). Consultations in which GPs initially did not plan to refer a benign lesion (after confirmation by teledermoscopy) but then changed their decision could be due to an insistent patient. However, we know from dermatology experience that dermatologists have specialized treatment equipment available, such as laser and light therapy. It is also likely that GPs are not aware of these (aesthetic) treatment options before sending the teledermoscopy consultation. The advantage of teledermoscopy is that GPs are informed about these treatment options due to the TD response and that patients can receive this treatment. The third limitation is that only the teledermoscopy consultation data extracted from the Ksyos system were accessible for our study. Although Ksyos is the largest store-and-
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