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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 6  |  Issue : 2  |  Page : 144-148

Teledermatology in the era of COVID-19, perspective from a developing country: Are we future-ready?


1 Department of Dermatology, Dr. Sampurnanand Medical College, Jodhpur, Rajasthan, India
2 Department of Dermatology, Sardar Patel Medical College, Bikaner, Rajasthan, India
3 Departments of Dermatology, Mittal Hospital, Ajmer, Rajasthan, India
4 Department of Orthopaedics, Dr. Sampurnanand Medical College, Jodhpur, Rajasthan, India

Date of Submission01-Jun-2021
Date of Decision25-Jan-2022
Date of Acceptance31-Jan-2022
Date of Web Publication26-Aug-2022

Correspondence Address:
Kamaldeep Singh
9/20, Vidhyadhar Nagar, Jaipur - 302 039, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cdr.cdr_46_21

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  Abstract 


Background: With the advent of the COVID-19 pandemic, the medical fraternity across the world, including India, is facing unprecedented challenges, and to cope with this, creative solutions are required. During this COVID-19 crisis, telemedicine has emerged as a weapon to reduce disease transmission while continuing with non-COVID care. Objectives: The purpose of this study is to highlight the changes and challenges in dermatology practice, to explore the usefulness of tele-dermatology during the pandemic, and to understand the dermatologist's perspective. Materials and Methods: An online cross-sectional survey was done among Indian dermatologists to evaluate the changes in their practice, impact of telemedicine, and their experience, during COVID-19. Results: A total of 177 responses from qualified Indian dermatologists were analyzed. Teleconsultation was done by 20.5% of consultants before lockdown which increased up to 82% after lockdown. Most commonly preferred device was mobile phone (83%), and the most common format was chat applications (WhatsApp/Messenger) (55.7%). Discontinued consultation was due to technical issues, patient's misbehavior, and poor-quality clinical photographs. Only 13.5% of practitioners were satisfied with teledermatology. Conclusion: With the onset of the COVID-19, the shift of clinical care to telemedicine practice has hastened. However, continuous investment in systems and technology as well as refinement of regulations for telemedicine is needed to sustain its widespread adoption.

Keywords: COVID 19, developing country, teleconsultation, teledermatology, telemedicine


How to cite this article:
Choudhary P, Mehta RD, Sharma D, Kacchawa D, Ghiya BC, Singh K. Teledermatology in the era of COVID-19, perspective from a developing country: Are we future-ready?. Clin Dermatol Rev 2022;6:144-8

How to cite this URL:
Choudhary P, Mehta RD, Sharma D, Kacchawa D, Ghiya BC, Singh K. Teledermatology in the era of COVID-19, perspective from a developing country: Are we future-ready?. Clin Dermatol Rev [serial online] 2022 [cited 2022 Dec 3];6:144-8. Available from: https://www.cdriadvlkn.org/text.asp?2022/6/2/144/354755




  Introduction Top


Telemedicine is defined as the delivery of health-care measures to remote areas, using electronic, audio, and visual means, for the diagnosis, prevention of disease, research and evaluation, and education of health-care providers to improve health.[1],[2],[3]

Telemedicine appears to be the need of the hour in this COVID-19 pandemic and has emerged as an option to protect patients, clinicians, and the community from exposure. It may allow physicians and patients to communicate round the clock and maintain non-COVID care using smartphones or webcam-enabled computers.[4],[5],[6] Telemedicine facilitates provision of quality health care, not only for COVID patients but also for the non-COVID population. Most of the patients are reluctant to physically approach health-care delivery system primarily because of the risk of contracting COVID and second due to the stigma of being branded as COVID patients when visiting such establishments.

Recently, many articles have highlighted the use of telecommunication as a useful tool during COVID-19 for dermatology practice.[6],[7],[8],[9] The purpose of this study is to evaluate the changes that have occurred in dermatology practice during the COVID-19 pandemic. It aimed to investigate the acceptance and impact of telemedicine on the current clinical practices, while enlightening the benefits as well as delineating the challenges faced by treating physicians. The targeted population, including both the dermatologists and advice seekers in our study, resides in remote areas, which are not well versed with the modern cyber platforms of socioprofessional interaction.


  Materials and Methods Top


Subjects

This is an online survey-based study of dermatologists practicing in India.

Data collection and procedure

An online survey was conducted from February 5, 2021, to February 15, 2021, to collect the information. A structured questionnaire using “Google Form” was sent to dermatologists through E-mail and WhatsApp, and the participants were requested to share this questionnaire among their networks. Reminder e-mails and messages were sent on a daily basis to increase participation. Participants were provided the option for consent before participation in the online survey. The entire questionnaire took approximately 10 min to complete.

Questions included were based on participant demographics, changes in their practice and teaching during COVID-19, use of virtual or e-health technologies, and attitudes/opinions on their experiences of teledermatology.

Data analysis

Data was entered in SPSS software version 26 (IBM Corp., Armonk, New York, USA) for statistical analysis. Frequencies/percentages were summarized for all categorical variables, and McNemar and Wilcoxon signed-rank tests were implied when appropriate. P < 0.05 was considered statistically significant.


  Results Top


A total of 186 responses from consultant dermatologists practicing in different parts of India were received and analyzed [Figure 1] and [Table 1]. Responses were checked for duplication. A total of 177 responses were included in analysis after deleting 9 duplicated responses. Out of the total, 63.27% (112/177) were male participants while females represent 36.7% (65/177) with a male to female ratio of 1.72:1.
Figure 1: Response-wise dispersion map

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Table 1: HRA classification of Indian cities

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Approximately, 32.2% (57/177) of respondents were working at the government hospitals and medical colleges and 42.93% (76/177) had their own private clinic, whereas 24.85% (44/177) of respondents practiced at both private and government setup.

Teleconsultation was not routinely used before this pandemic in India. Only 20.5% (36/177) of the participants were doing teleconsultation in pre-COVID era and that too especially for follow-ups. After lockdown, its use increased exponentially among responders reaching a total of 82.1% (145/177). Approximately, 62% (109/177) consultants started using teleconsultation for the first time after lockdown due to COVID pandemic, whereas 17.9% (32/177) had yet not adopted this format [Chart 1].



On asking the preferred method of consultation since lockdown, only 18.8% (33/177) favored teleconsultation over physical, whereas 59% (104/177) opted for both physical and virtual consultation, and 20.5% (36/177) chose physical consultation over teleconsultation, even after social distancing measures were implemented.

This catastrophic outbreak has profoundly affected dermatology practice. As before pandemic, most of the participating dermatologists (51.9%, 92/177) were consulting more than 30 patients per day, and approximately 19% (34/177) of doctors were seeing between 21 and 30 patients per day by physical consultation method. The number of patients coming to them for in-person consultation drastically reduced after lockdown (P = 0.0001) with only 11.2% (20/177) of consultants attending more than 30 patients daily, while 36.7% (65/177) completely stopped seeing. After unlocking, the average number of patients seen per day increased significantly as compared to lockdown (P = 0.0001) [Table 2].
Table 2: Changes in patient volume by physical consultation

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Most of the dermatologists (20.3%, 36/177) who were using teleconsultation before the pandemic were attending only few patients (0–10) per day through this mode. However, nationwide lockdown has shifted the consultation method from physical to teleconsultation. Virtual consultations have increased during the lockdown; 41.2% (73/177) of practitioners were consulting 0–10 patients per day and 10.2% (18/177) were attending 11–20 patients per day [Table 3].
Table 3: Changes in patient volume by teleconsultation

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Most of the patients seen during this pandemic were of clinical dermatology; only few were related to cosmetology. Approximately 47% of the practitioners were using all the modes – video, audio, and text. Most commonly used device for teleconsultation was mobile (83.7%) followed by laptop (24%), desktop (5.8%), and tablet (5.8%). The most commonly preferred format for telecommunication was chat platform (WhatsApp/Messenger) (57.69%) followed by audio or video calls (36.5%), mobile apps (32.7%, 34), and through data transmission system (mail/fax) (3.84%).

Despite the guidelines, only few practitioners (15.8%, 28/177) took online course for teleconsultation. Approximately two-third of dermatologists (76.8%, 136/177) used to verify the patient's details before teleconsultation, as mentioned in telemedicine practice guidelines. Consent for consultation and record maintenance were done by 52% and 65.7% of doctors, respectively. Clinical photographs were asked by 86.1% of dermatologists before consultation. 52% of the respondents were providing scanned written prescription and fee receipt after teleconsultation was given by 48.5% of dermatologists. 65.9% of practitioners among those doing teleconsultation were charging equal to their physical consultation charges and 24.2% were charging less than that.

There are many reasons causing interruptions in telecommunication from both clinician and patient side. According to this survey, 26.2% (38/145) of dermatologists faced this problem and discontinued consultation in between. Among these, the most common causes were technical issues ((31/38), poor connectivity (30/38), inability to diagnose (10/38), patient's misbehavior (6/38), poor-quality clinical photographs (18/38), and refusal to consent (8/38). Although telemedicine is an easy measure to practice for dermatologists due to easy snap-shot diagnosis of many dermatoses, the possibility of misdiagnosis or delayed responses still looms. According to this survey, 94.4% (137/145) dermatologists suggested physical consultation to their patients who were undiagnosed or not responded to treatment.

The advent and utilization of telemedicine have been hastened because of COVID-19 pandemic, but only 13.5% (24/177) of practitioners were satisfied completely and 44.1% (78/177) were satisfied to some extent, in terms of diagnosis. Rest (42.3%) were either unsatisfied or were not practicing teledermatology.


  Discussion Top


As per strategic preventive measures to reduce the risk of person-to-person transmission of the coronavirus, Indian government introduced nationwide lockdown which enforced shutdown of many nonessential services. During this lockdown, routine outpatient clinics were cancelled throughout the country. Therefore, during this crisis, telemedicine has emerged as a critical tool and platform to provide uninterrupted medical care to patients with an attempt to reduce transmission of COVID-19 spread.[7],[10]

In India, until corona pandemic, there was no legislation on telemedicine practice, through phone or internet-based platforms. The unavailability of proper guidelines and rules poses a risk for both doctors and patients. Finally, on March 25, 2020, the Board of Governors, National Medical Commission, has announced Telemedicine Practice Guidelines, which allows registered medical practitioners (RMP) to provide health care using telemedicine.[11],[12] The guidelines state that teleconsultation should not be anonymous, and both RMP and patients should verify and confirm each other's identity before consultation. RMP should display the name, qualification, and medical registration number on prescription, website, electronic communication, and receipts given to his/her patients. Patient consenting and record maintenance are necessary for any telemedicine consultation.

Telemedicine may play a critical role to curb the outbreak by reducing unnecessary patient's visits to hospital, reducing overuse of emergency departments, and providing remote monitoring of patient's health status as well as reducing the risk of clinician's exposure to infections. It also helps in conserving the health-care resources and maintaining the uninterrupted, continuous, safe, and quality patient care while following the standard operating procedures. Moreover, it helps to do away with the waiting time outside popular practitioners' clinics.

Although telemedicine has a wide range of potential benefits, still it has some disadvantages and challenges to consider. The main ones that can be envisaged are alteration in the relationship between health professionals and patient, payment modalities, reimbursement policies, ethical consideration, record maintenance, and privacy protection issues.[4],[13] Lack of access and technological awareness are important concerns among people of developing countries. The implementation of telemedicine services on a large scale and making people aware of its benefits seems to be an uphill task.[6]

Many dermatologists in India are also adjusting their practice to accept the telemedicine format. Telemedicine is an easy and more practical alternative to be used in dermatology because in dermatology snap-shot diagnosis is the advantage.[7],[14] The efficacy of teledermatology depends on quality of internet connectivity, images sent by patients, and patient's compliance. Unfortunately, virtual dermatology examinations lack the elements of palpation, so there is always a possibility of misdiagnosis. This can be supported by improvements in personal mobile technology, networks proliferation, and changing the regulatory and reimbursement structures. At last, medicolegal consequences may present as a serious issue with this format, which requires proper statutory barriers.[3],[6],[15]

Our survey showed that telemedicine was not a preferred method by dermatologists in India before lockdown, as only 20.5% of consultants were using it; similar was observed by Bhargava and Sarkar.[6] Teleconsultations have increased during the pandemic, as after the lockdown, 61.5% of dermatologists have adopted this method. These changes in practice are comparable with Bhargava and Sarkar's study.[6] Most commonly used mode of communication was WhatsApp and Messenger, as in Bhargava and Sarkar.'s study.[6] Jakhar et al. in their study also documented WhatsApp as an important interface between patients and dermatologists.[7] Social media platforms although have widespread access to the masses, using them for consultation is a double-edged sword. It may be easy to use, but privacy of the patients and consultants, charges of consultation, inappropriate behavior, etc., remain an issue.

According to this survey, 84.2% of the contributors have not taken any training before starting virtual practice; hence, only 48.5% and 52% of dermatologists were providing fee receipts and prescriptions, respectively, after teleconsultation. Majority of the doctors were unable to provide bill and scanned prescription, according to Bhargava and Sarkar.'s study.[6] To successfully implement digital platform in medicine effective training module for physicians along with guidelines regulating malpractices are required.

All (36.8%) consultants who stopped consulting patients physically when lockdown was imposed were working in private, while consultants working in government hospitals had to continue with physical consultation, as there were no arrangements for teleconsultation in government setup. In resource-limited country like India where majority of the population is dependent on public hospitals for their healthcare needs, telemedicine can be maximally used only if this facility is available in government hospitals. Facilities for this have to be made available at peripheral centers, and user-friendly mobile apps can help both patients and physicians.

Technical issues, poor internet connectivity, misdiagnoses or under-diagnosis due to poor quality of pictures, and patient's misbehavior were the common issues faced by dermatologists during their teledermatology practice. Bhargava and Sarkar.'s study showed that more than half of the respondents (54%) see a future for teldermatology (TD), whereas 30.6% of practitioners were dissatisfied in terms of diagnosis, according to our survey.[6] Patient satisfaction is the key component of telemedicine and will drive its evolution; for which certain improvisations are required. With the recent and rapid incorporation of telemedicine in dermatology practice, as well as the unpredictable future of the pandemic, the scope of telemedicine is likely to expand. However, more sustainable and comprehensive changes and standardization are the next steps in improving the utility of telemedicine.

Limitations

There are several limitations of this study. The sample size is small and cannot be expected to represent the whole dermatology community. Although Google Form was forwarded to practicing dermatologists, this being an anonymous Google survey, identity of the respondents to be consultant dermatologists cannot be relied upon.


  Conclusion Top


Telemedicine can serve as a medium for patient care that is provided at a distance using information technology, including cell phones, computers, or other electronic devices. After the COVID-19 pandemic, telemedicine is a rapidly evolving modality that is capable of improving access to quality health care for the patients meanwhile containing spread of disease. By tackling the challenges of implementation and training, improving education and awareness, streamlining technology, and collaborating with patients and clinicians, the field of dermatology may benefit from telemedicine in the years to come.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Kirsh S, Su GL, Sales A, Jain R. Access to outpatient specialty care: Solutions from an integrated health care system. Am J Med Qual 2015;30:88-90.  Back to cited text no. 1
    
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Sood S, Mbarika V, Jugoo S, Dookhy R, Doarn CR, Prakash N, et al. What is telemedicine? A collection of 104 peer-reviewed perspectives and theoretical underpinnings. Telemed J E Health 2007;13:573-90.  Back to cited text no. 2
    
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Villani A, Scalvenzi M, Fabbrocini G. Teledermatology: A useful tool to fight COVID-19. J Dermatolog Treat 2020;31:325.  Back to cited text no. 5
    
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Bhargava S, Sarkar R. Impact of COVID-19 pandemic on dermatology practice in India. Indian Dermatol Online J 2020;11:712-9.  Back to cited text no. 6
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