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JUNE 2017
FundingsupportforthisinitiativewasprovidedbyUnitedHealthFoundation
QuickGuidetoStore---ForwardTeledermatologyforReferringProviders
KarenMcKoy,MD,ScottNorton,MD,CharlesLappan,MBA,MPAATATeledermatologySpecialInterestGroup
June2017
1. Work Flow
2. Camera
• Digital(avoidsmartphones;whiletheimage-capturingabilityofsmartphonesvarywidely,certainsmartphoneswithhigh-qualityimage-capturingcapabilitiescouldbeconsideredtocaptureimages.However,itisimportanttoensurethatsuchimagesaretransmittedsecurelyonaHIPAAcompliantplatform)
• Minimum800X600pixels;preferredresolutionof1024X768pixelsorgreater(about
0.8Megapixels)
• Macromodecapabilityisideal(“flower”image)
3. Takingthe Image
• Background---Useasolid,neutralcolorperpendiculartocameraangle.
• Lighting---Diffuse,indirectlightisbest.Avoidshadows.Indoors–fluorescentday---lightorfullspectrumbulbsarebest(avoidincandescent).Outdoors–usewell---lit,butevenlyshadedareaifsunny.
• Flash---Helpstoeliminateshadows.Testtoseeifneeded.Maycausewhite---outiftoo
close.
Referralsite
HIPAA compliant
electronictransmission
Consultingdermatologist
• Compression---UseJPEGmediumorlowsetting(nomorethan20:1).• Focus---Adjustcameraandpatienttohavecameraangleperpendiculartotheskin
lesionsbeingimaged.Useauto---focuswithareaofinterestincenterofframe.Ifnotpossible,focusfirstontheareaofinterest,depressshutterbuttonhalf---waytofocus,thenmovethecameratocentertheimagebeforefullydepressingshutterbutton.
• Views---Taketoshowlocationandarrangementoflesions.Takeseveralviews
o Far---entirebodyorobviousregiono Medium---areainvolvedcentralbutincludeananatomicallandmarksuchasthe
navelorhando Close---Up---ifyouhaveamacrocapacity–the“flower”image,thiscanbetaken
under18inchesfromtheskin–otherwiseyoumayusetheopticalzoom,ifpresent,tofocusforaclose---up.Usestraightonandobliqueviewsforclose---ups.
• ExtraTips---Useachaperoneifneeded;avoiddistractingjewelryandclothing;inhairy
areastapeorpressbacktoshowunderlyingskinchanges.Forfaceshots,eyesshouldbeopen.Usemeasurementtoolsasappropriate.
4. Before&AfterSendingtheConsult
• Reviewimagesforfocusandadequateviewsbeforethepatientleaves.
• Sendonlyhelpfulandclearimagestotheconsultant.
• Donotalterimagesinanywayaftertaken.
• Labelimages,transmittedtextandconsultantresponsetobecomepartofasecure,
retrievablemedicalrecord.
TeledermatologyImagingSets
Showentireanatomicunit(e.g.trunk)ifalesionorrashiswithinthisunit.
ArAr
ComplementaryViewsIfconditioninvolvescertainlocations,thenchecktoseeifanycomplementaryviewsneedtobelookedatorphotographed.
IfInvolved: Include Look/Ask/?IncludeHands Feet Elbows/KneesFeet Hands GroinElbows Knees ScalpKnees Elbows ScalpScalp Face Knees,ElbowsPoplitealfossa Antecubitalfossa Neck,Face,handsAntecubitalfossa Poplitealfossa Neck,Face,handsNail(any) Allnails OralMucosaGroin Buttocks Hands&FeetFace(Eyebrows) ScalpOralMucosa Genitals
References
1. KrupinskiEetal.AmericanTelemedicineAssociation’spracticeguidelinesforteledermatology.Telemedicineande---Health2008(April):14:289---302.
2. PakHS,LappanCM.Basicguidetodermatologicphotography.Unpublisheddocument,
2005.Availableat:http://www.americantelemed.org/files/public/membergroups/teledermatology/telederm_DermatologicPhotography.pdf
QuickGuidetoLive---InteractiveTeledermatologyforReferringProviders
AprilW.Armstrong,MD,MPHATATeledermatologySIG
June2017
1. Work Flow
Introducewhoispresentandtheroleofthecoordinatorifoneispresent.
2. EquipmentA. VideoconferencingEquipmentToconductlive---interactiveteledermatology,recommendationsforvideoconferencingunitsincludethefollowing:
• H.264videocompressionstandardorbetter• H.323compliant• H.261videocompressionstandardcompatibility• G.711audiocompressionstandardorbetter• LiveVideoresolution4CIF(704x480)orhigher• ContentresolutionXGA(1024x768)orhigher• Capableofconnectingat384kbpsrunning4CIF@30fps
Synchronous,
basedcommunicationoversecure,
broadbandtransmission
Referralsite• • • • •
Consultingdermatologist
B. Video---FormatGeneralExaminationCamerasVideo---formatgeneralexaminationcamerasareperipheralsattachedtothevideoconferencingunitsthatallowforclose---upexaminationofskinlesions.Recommendationsforvideo---formatgeneralexaminationcamerasincludethefollowing:
• Standarddefinitionorhigh---definition• Abletoscan,zoom,autofocus,andfreeze---framecaptureskinlesions• Containsinternallightingsourcetoilluminateskinlesions• Imagepolarizationfeaturepreferredbutnotgenerallyrequired
C. ConnectivityBecauseconnectionspeedhasaprofoundimpactonvideoimagequality,aconnectionspeedofatleast384kbpsbetweenthereferralandconsultantsitesisrecommended.Mostlive---interactiveteledermatologyprogramshavetransitionedfromISDNtointernetprotocol(IP).Currently,mosthigh---speedT1lineshaveconnectivityspeedsofatleast1.5mbps.
3. CapturingVideo---BasedImagesImagequalityinlive---interactiveteledermatologycanvarysignificantlydependingonamultitudeoffactors,includingconnectionspeed,operationalexperienceoftheteledermatologycoordinator,andwhetherfreezeframeisused.Generaltipsoncapturinghigh---qualityvideo---basedimagesaredetailedbelow.
• Connectivity---Minimumof384kbpsconnectionspeedbetweenreferralandconsultantsitesisrecommended.
• Lighting---Becausetheilluminationdeviceonthevideo---formatgeneralexamination
camerasmaynotprovidesufficientilluminationonitsown,werecommendadditionalindoorlightingusingfluorescentdaylightorfullspectrumbulbs.
• Views---Holdthecameraatadistanceinitiallytoshowthegeneraldistributionofa
rashorlocationofaskingrowthbeforeobtainingclose---upimages.Whenmovingthecameratoshowthegeneraldistributionofarash,thecoordinatorshouldobtainfeedbackregardingthespeedofcameramovementfromthedermatologisttoensureadequateimagequalityattheconsultant’ssite.
• Positioning---Ifthedermatologycameradoesnotcontainanimagevieweronthe
cameraitself,itisimportanttopositionthepatientinbetweenthedermatologycameraandthevideoconferencemonitorinonelineofsightsuchthatthecoordinatorcaneasilyseewhetheranimageiscapturedcorrectlyonthevideomonitor.
• VerbalizationofBodyRegionsBeingExamined---Asthecoordinatormovestheskinexaminationcamera,heorsheneedstocontinuouslyverbalizethepartofthebodythatisbeingcaptured.Thishelpstoorientthedermatologisttothelocationofthelesions.
• Focus---Forcapturingclose---upimages,adjustthecameraangletoensurethatthe
cameraisperpendiculartotheskinlesions.Holdthecameraasstillaspossibletoshowtheclose---upimages.Offertotakefreeze---frameimagesifimagesfromlivefeedsareunclear.
• Freeze---frameCapture---Mostvideo---formatgeneralexaminationcamerasare
equippedwiththefreeze---framefeature.Usingthisfeatureproducesstillimagesthatarehighlyusefulfordiagnosis.Itisespeciallyimportanttousefreeze---framecapturewhenconnectionspeedislow,whichcanresultindegradationofimagequalityformovingvideoframesbutnotnecessarilyaffectstillimagescapturedthroughfreeze---frames.Freezeframesallowthedermatologisttoappreciatefinesurfacefeaturesoftheskinlesionsandminimizemuchoftheimagedegradationthatoccurswithscanningwiththecamera.
• Otherconsiderations---Avoiddistractingjewelryandclothing;inhairyareas,tapeor
pressbacktoshowunderlyingskinchanges;useachaperoneifnecessary;usemeasurementtoolsasappropriate.
4. BeforeandAfteraLive---InteractiveTeledermatologyConsult
A. BeforeaLive---InteractiveTeledermatologyConsult
• Ensurethatthedermatologisthasreceivedpatienthistoryandreferralforms.
• Arriveearlytoestablishvideoconferenceconnection,connecttheperipheralattachments,andcheckallequipmenttoensureproperfunctioning.
• Reviewthepatient’sreferralformtoidentifybodyareasthatwillneedtobe
uncoveredandimagedforexamination.B. AfteraLive---InteractiveTeledermatologyConsult
• Ifthecamerahasaprobe,placeathermometercondomontheprobeduringpatientexaminationandchangethethermometercondomaftereachpatient.
Live---InteractiveTeledermatologySetupFigure1:Patientatreferralsitecommunicateswithconsultingdermatologistinrealtime.
Figure2:Consultingdermatologistevaluatespatientskinlesionsinrealtime.
References
• KrupinskiEetal.AmericanTelemedicineAssociation’sPracticeGuidelinesforTeledermatology.Telemedicineande---Health2008(April):14:289---302.
• GoldyneMEandArmstrongAW.TheTeledermatologyPracticeGuide.Availableby
requestviaCaliforniaTelemedicineandeHealthCenter,http://www.cteconline.org/publications.php#program.