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Teledermatoscopy – mole assessment for everyone

Sweden Distance monitoring
Early diagnosis and action is of great importance for the survival of patients with malignant melanoma. Until 2012, a referral-free mole assessment was offered at the University Hospital of Umeå in Region Västerbotten that was supposed to support the entire population in Västerbotten. However, the patients who sought help there weren’t always those with the greatest needs. As of 2014, mole assessment is offered at all healthcare centres in Västerbotten. The patient is photographed with a dermatoscope attached to a mobile phone. The images are stored in the patient’s medical record and a referral with a reference to the images is sent to Dermatology Clinic. Based on the images, a dermatologist judges whether or not the condition needs surgery, treatment or if it is best left unattended.
Healthcare becomes more equitable for all residents in the county and the time to diagnosis and potential treatment is shorter. The number of unnecessesary surgeries has declined and the lead times has shortened considerably. Fewer physical visits has also led to less travel for the the patients with positive effects for the environment as well as economical gains.
Inhabitants in the entire county of Västerbotten where there is a suspicion of skin cancer. Doctors, nurses and medical secretaries in primary care as well as dermatologists and medical secretaries in the hospital
mole.png
As of 2014, mole assessment is offered at all healthcare centres in Västerbotten. The patient is photographed with a dermatoscope attached to a mobile phone.

Quotes/testimonials

"Now all citizens in Västerbotten can get specialist assessments of their skin lesions, on equal terms. A brilliant example of cooperation across clinics and the department of e-health where the needs of the customer has been in the centre."

—Virginia Zazo, Senior Clinician and Director of Studies, Dermatology Clinic, Region Västerbotten

Elaboration

Needs and challenges

Malignant melanoma is the most dangerous form of skin cancer and also the one that has increased the most. Dermatologists have a better ability to diagnose malignant melanoma than general practioners. Historically, mostly patients living close to a hospital have been checking their skin lesions, but it not always those who have the biggest needs.

By offering the possibility for everyone to have their skin lesions checked at their local healthcare centre, a more accessible and equal healthcare is created. The Dermatology Clinic as well as the primary care saw the need to expand the accessibility to mole assessment. 

Solution and function

The patient visits their local healthcare centre. A doctor or other healthcare staff photographs the suspected skin lesions with a dermatoscope, which is a magnifying glass with lighting that can reflect the skin in detail. A dermatoscope attached to a smartphone is used in Region Västerbotten.

The photograph is taken with the phone’s camera and is stored in an image storage system connected to the medical record. The primary care doctor sends a referral to the Dermatology Clinic with a reference to the images of the patient’s skin lesions. The dermatologist at the hospital judges whether or not the condition needs surgery, treatment or if it is best left unattended, based on the images. The patient and the doctor who sent the referral get feedback from the dermatologist after about a week after the images where taken. About 4500 teledermatoscope referrals are sent to the Dermatology Clinic each year. 

Implementation

Before the service model was implemeted at a broader scale a pilot study was carried out in the healthcare centres in Västerbotten and the Dermatology Clinic at the University Hospital of Umeå. The pilot was partly financed through a bugetary allocation for development at the Department of e-health which shortened the decision-making procedures and facilitated a quicker start and implementation.

The pilot showed positive results and decision was made to implement the service model in all 40 healthcare centres in Region Västerbotten. Since then there has been continuous work with improving routines and work models. 

Despite the fact that the cost for dermatoscopes and smartphones was relatively low, about 1500 euros, it was decided that the central budgetary allocation for development would be used to finance the equipment for all healthcare centres. Taking the financial decision at a central level meant that the implementation could be done in a fast pace. 

Apart from establishing technical conditions, routines were also created. The routines included everything from how the patients were being photographed, to referral management and record keeping. An instructional film was produced that was used in the training of the staff. A number of training session with involved staff were performed at the three hospitals in the region. The implementation was done with the help of a project manager that was given a 30% employment. 

Two dermatologists has also taken a specific course in dermatoscopy - The Academic Expert in dermoscopy -. It is a two years postgraduate distance learning course for physicians  and nurses who wish to gain advanced expertise in the theoretical and practical diagnosis and management of skin tumors. Certificate of the Medical University of Graz. Granted the official title "Academic Expert in Dermoscopy". 

Economy

In 2014 the costs for the dermatoscope DermLite DL3N was about 1250 euro and for an iPhone 4s 310 euro. The total cost for dermatoscopes and smartphones for all 40 healthcare centres was about 62000 euro. The course “The Academic Expert in dermoscopy” cost 8500 euro.

The cost for the training of the staff could be kept quite low since it was mainly done using an instructional film that was accessible online. 

Since Region Västerbotten already had a medical record with image storing possibilities there were no extra costs there.  

Process

It is important that this type of change is driven jointly by the primary care and hospital care and that the decision about implementation is taken at a central level.

The work model also had support from the national work with standardized care processes and the project “Better flow for melanoma” run by the Swedish Association of Local Authorities and Regions, SKL.  

Organisation and politics

The decision about implementing mole assessment in primary care was anchored at the highest level in the management of the region.

The politicians were also positive to replacing the referral-free mole assessment at the University Hospital in Umeå with the new work model where all healthcare centres could offer mole assessment.  

Follow-up/monitoring

Surveys have been conducted with a focus on benefits for the patient, user friendliness, the use of the method, if the answers to the referrals are satisfactory etc.

Continuous follow-up is also done on the number of referrals, to what extent pathological samples decline, time to diagnosis and surgery, the thickness of the melanoma, diagnostic accuracy, deviations in referral handling, the number of patient travels, times for standardized care processes etc.

The increase in the number of referrals has leveled off which might be due to the fact of increased competence to assess moles at the healthcare centres. The patients that have to undergo surgery at the hospitals have cancer diagnoses to a higher extent than earlier, which means that the resources are being used for the right patients. 

Communication

There are established routines for the introduction of new staff, as well as practical information regarding work models, referrals etc. Information is also given through local media, various fairs and events, for example the melanoma week in may where referral free mole assessment is offered for all inhabitants, and that the care givers remind their patients of this possibility.

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More about effects

There are many positive effects from this solution. Press "show" to learn about the benefits this solution can provide for the patient and the care giver.

Effects for the patient 

  • Shorter time to diagnosis and possible action 
  • More equitable healthcare throughout the county 
  • Less travels 
  • Fewer unnecessary operations, which is important since there is a lack of pathologists 
  • Skin lesions are assessed by a dermatologist 

Effects for the care giver 

  • More efficient processing of patients 
  • Competence increase in the primary care 
  • Early diagnosis which in the long run reduces treatment costs 
  • Decreased strain on the Department of Pathology with benign lesions which allocates resources for managing cancer diagnoses 
  • Screening of skin cancer has improved 

Other effects 

  • Positive effects on the environment 
  • Reduced costs for patient travels 

Learnings

  • The quality of the images can be improved if the staff taking the photographs get more training on how to take the photos.
  • Development is being done by the supplier to simplify the storage of the images, which would increase patient safety. In the future, this might mean that the patients can send pictures by themselves.
  • More modern phones, the current ones are from 2014, would give better quality to a relatively low cost. 

The work model with teledermatoscopy is an example on how specialist care can be made available in primary care to create a more equitable health. The same principle with image referrals is also used for other skin conditions in Region Västerbotten, see the link to an article in Läkartidning below. The work model kan also be used in other healthcare activities and for other groups of patients, for example within ophthalmology. 

Article in Läkartidningen: Remiss med bild – jämlik och kostnadseffektiv vård

Virginia Zazo, Senior Clinician and Director of Studies, Dermatology Clinic, Region Västerbotten 

virginia.zazo@regionvasterbotten.se  

  • Dermatoscope: Dermlite DL3N 
  • Smartphone: Iphone 4s 
  • Medical record: NCS Cross 
  • Image storing system: Picsara 

The concept has been developed by Region Västerbotten and consists of technical solutions from multiple suppliers, for example DermLite, Apple, Evry and CSAMhealth.