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.