Instructions: 

This draft set of practice guidelines for teledermatology incorporates recommendations for setting up and maintaining a teledermatology practice involving store-and-forward and/or real-time video teleconferencing consultations.  The document was developed by members of the ATA Teledermatology Working Group, a multidisciplinary, broad base organization.  The Working Group included representatives from clinical, technical, industry, medical societies, government and other potentially affected groups such as ATA’s Special Interest Groups, American Academy of Dermatology, the National Institutes of Standards and Technology and US Department of Defense.

We encourage and appreciate all comments on the document.  Please provide comments via this online tool by September 24, 2007.

Following the commenting period, the Working Group will carefully consider all submitted comments and assemble a final document for distribution.  The final document will continue to be updated on a periodic basis.  Please distribute this document to colleagues who may wish to add their comments as well.

Elizabeth Krupinski, PhD¹, Anne Burdick, MD², Hon Pak, MD³, John Bocachica, MD⁴, Lucius Earles, MD⁵, Karen Edison, MD⁶, Marc Goldyne, MD⁷, Tom Hirota, DO⁸, Joseph Kvedar, MD⁹, Karen McKoy, MD, MPH¹⁰, Dennis Oh, MD¹¹, Dan Siegel, MD¹², Nina Antoniotti, PhD¹³, Ivan Camacho, MD¹⁴, Lisa Carnahan, PhD¹⁵, Paul Boynton, PhD¹⁵, Richard Bakalar, MD¹⁶, Richard Evans, MS¹⁷, Al Kinel, PhD¹⁸, Peter Kuzmak, MSBME¹⁹, Brian C. Madden, PhD²⁰, Sandra Peters, PhD²¹, Lynne Rosenthal, PhD¹⁵, Scott Simmons, MS², Jonathan Linkous²², Jordana Bernard²²

¹ Arizona Telemedicine Program University of Arizona, Tucson, AZ
² Associate Dean of Telemedicine and Clinical Outreach Miller School Medicine University of Miami, Miami, FL
³ Chief, Advanced Information Technology Group Telemedicine and Advanced Technology Research Center, Ft. Detrick, MD
⁴ Departments of Dermatology and Teledermatology Alaska Federal Health Care Access Network, Anchorage, AK
⁵ Section of Dermatology Department of Medicine Mt. Sinai Hospital Chicago, IL
⁶ Department of Dermatology University of Missouri Health Care, Columbia, MO
⁷ Department of Dermatology University of California San Francisco, San Francisco, CA
⁸ Dermatology Services Madigan Army Medical Center & Department of Dermatology F. Edward Hebert School of Medicine Uniformed Services University of Health Sciences, Bethesda, MD
⁹ Center for Connected Health Partners HealthCare System, Inc. Department of Dermatology Harvard Medical School, Boston, MA
¹⁰ Lahey Clinic Department of Dermatology Burlington, MA & Department of Dermatology
Harvard Medical School, Boston, MA
¹¹ Department of Dermatology University of California San Francisco & Dermatology Service San Francisco VA Medical Center, San Francisco, CA
¹² Department of Dermatolgy SUNY Downstate, Brooklyn, NY
¹³ Marshfield Clinic TeleHealth Network, Marshfield, WI
¹⁴ Department of Dermatology and Cutaneous Surgery University of Miami, Miami, FL
¹⁵ Information Technology Laboratory National Institute of Standards and Technology, Gaithersburg, MD
¹⁶ IBM Global Healthcare IBM Corporation
¹⁷ Utah Telehealth Network, Salt Lake City, UT
¹⁸ Director of Alliances Kodak Corporation, Rochester, NY
¹⁹ Department of Veterans Affairs VistA Imaging Project Silver Spring, MD
²⁰ Program Director VISN 2 Telemedicine Department of Veterans Affairs & Department of Dermatology University of Rochester, Rochester, NY
²¹ American Academy of Dermatology, Washington, DC
²² American Telemedicine Association, Washington, DC

The American Telemedicine Association (ATA), with more than 2,500 members, is the principal organization of telemedicine practitioners in the United States. The ATA is a nonprofit society that seeks to bring together diverse groups from traditional medicine, nursing, allied health professionals, academic medical centers, technology and telecommunications companies, e-health, medical societies, government and others to overcome barriers to the advancement of telemedicine through the professional, ethical and equitable improvement in health care delivery. The ATA has strong ties and strategic relationships with host organizations with other international telemedicine societies. The ATA will occasionally define new practice guidelines and technical standards for telehealth practice to help advance the science of telehealth and to improve the quality of service to patients. Existing practice guidelines and technical standards will be reviewed for revision or renewal periodically.

The practice guidelines and technical standards generated by ATA have undergone a thorough consensus and rigorous review, with final approval by the ATA Board of Directors. The practice guidelines and technical standards recognize that safe and effective telehealth practices require specific training, skills, and techniques, as described in each document. Reproduction or modification of the published practice guideline and technical standard by entities that do not provide these services is not authorized.

The primary care practitioner is responsible for the decision about the appropriateness of a specific procedure or course of action, considering all presenting circumstances. An approach that differs from the ATA guidelines does not necessarily imply that the approach varied from the standard of care. If circumstances warrant, a practitioner may responsibly pursue a course of action different from these guidelines when, in the reasonable judgment of the practitioner, such action is indicated by the condition of the patient, restrictions or limits on available resources, or advances in information or technology subsequent to publication of the guidelines. Nonetheless, a practitioner who uses an approach that is significantly different from these guidelines is strongly advised to document in the patient record information adequate to explain the approach pursued.

Teledermatology is one of the most active applications of telemedicine rendered in the United States. Dermatology is particularly suited to the use of advanced communication technologies and the Internet for delivery of care. [1-38] By using advanced communication technologies, dermatologists may be able to widen their reach to patients in a cost-effective manner, ameliorating the maldistribution of specialty care. The following Guidelines were designed to aid in the development and practice of coherent, effective, safe and sustainable teledermatology practices. Establishing Guidelines for teledermatology may improve clinical outcomes and promote informed and reasonable patient expectations.

The Practice Guideline for Teledermatology covers two major areas, reflecting the basic component processes associated with most teledermatology consultations: technical and clinical Administrative aspects of clinical teleconsultations in general are covered in the American Telemedicine Association’s TeleHealth Standards document. [39] In teledermatology, store-and-forward (S&F) communication typically refers to the sending or forwarding of digital images and associated patient data to the specialist for storage and consultation. For real-time video teleconferencing (VTC), providers and patients interact via live videoconferencing. The recommendations apply to S&F, VTC and hybrid (utilizing both S&F and VTC) modes for teledermatology.

The Guidelines contain Standards for the practice of teledermatology that are required whenever feasible and practical as determined by the referring clinician practicing under local conditions. These Standards are presented first in the document and are identifiable in the text when “shall” is used (indicated by bold italics). In the following section, the Guidelines contain recommendations for Best Practices that are indicated in the text by “should” to indicate an optimal recommended action, one that is particularly suitable, without mentioning or excluding others. The third section contains optional or permissible action indicated by “may/attempt to” to indicate additional points that may be considered to further optimize the teledermatology consult process.

A glossary of important terms, references to literature, and informative web sites are included at the end of the document for further consideration. An Appendix is included with information about the Digital Imaging & Communications in Medicine (DICOM) standard that is likely to impact the practice of teledermatology in the very near future.

III. OPTIONAL STEPS TOWARDS OPTIMIZING TELEDERMATOLOGY PRACTICES

This is not meant to be a comprehensive list of all existing standards, but rather provides a description of the standards most relevant to the practice of teledermatology.

a. ISO/TC42/WG18 12233: This standard was developed (by the International Standards Organization ISO [70]) for photography/electronic still picture imaging. Section 12233 includes a resolution test chart and three measurement methods, including a computerized method of measuring the spatial frequency response.

b. ITU-T: The International Telecommunications Union has established a series of standards (H.300) for VTC. It includes such sections as the H.320 series for circuit-switched, n x 64 (i.e., ITU-T); the H.323series: packet-switched/network, Internet Protocol; and the H.324: Plain Old Telephone Service (POTS).

c. Session Initiation Protocol (SIP): The Internet Engineering Task Force RFC 3261 also applies to VTC. SIP is a text-based protocol for initiating interactive communication sessions between users, including voice, video, chat, and virtual reality.

d. DICOM: The Digital Imaging & Communications in Medicine standard has a number of sections dealing with medical image handling, transmission, archiving, and display. Originally developed for Picture Archiving and Communications Systems (PACS) in radiology, many components of this standard are being adapted for use in other medical imaging applications. [67] DICOM currently has a visible light supplement that makes the DICOM standard relevant to teledermatology. Appendix A provides additional details on the rationale for migrating teledermatology to DICOM. Currently DICOM standards have two components:

e. JPEG/TIF/WAV: Some of the most common compression methods used for still images include the following. The method used depends on the achievable compression ratio and the number and types of artifacts created during compression. Lossless compression allows for the reconstruction of the exact original data prior to compression without any loss of information.

Lossy compression refers to methods that lose data once the image has been compressed and uncompressed. The level of compression and method used affect the amount of data loss and whether or not it is visually perceptible. The type and level of compression may vary depending on the type of exam. Different compression algorithms will achieve different compression ratios with varying degrees of artifacts. The choice of compression method and level should be reviewed periodically for each image and exam type, to insure that artifacts are not perceptible. It should be noted that lossy compression can affect the colors in an image.

f. HL7: Health Level Seven is one of several American National Standards Institute (ANSI) Standards Developing Organizations (SDOs) operating in the healthcare arena. Health Level Seven’s domain is clinical and administrative data. [72]

g. IHE: Integrating the Healthcare Enterprise is an initiative to improve how computer systems in healthcare share information. It promotes coordinated use of established standards such as DICOM and HL7 to address specific clinical needs to support optimal patient care. [73]

h. US HIPAA: The United Sates Health Insurance Portability & Accountability Act of 1996 (Public Law 104-191)calls for improved efficiency in healthcare delivery by standardizing electronic data interchange, and the protection of confidentiality and security of health data through setting and enforcing standards. [42,47] It has rules for:

i. JCAHO: The Joint Commission evaluates and accredits nearly 15,000 health care organizations and programs in the United States. An independent, not-for-profit organization, The Joint Commission is the nation’s predominant standards-setting and accrediting body in health care. Since 1951, The Joint Commission has maintained state-of-the-art standards that focus on improving the quality and safety of care provided by health care organizations. The Joint Commission’s comprehensive accreditation process evaluates an organization’s compliance with these standards and other accreditation requirements. Joint Commission accreditation is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. To earn and maintain The Joint Commission’s Gold Seal of Approval™, an organization must undergo an on-site survey by a Joint Commission survey team at least every three years. (Laboratories must be surveyed every two years.) [40]

Migrating Teledermatology to DICOM: There are two reasons for using DICOM for the creation of an image object.  First, it is desirable to create standard formatted dermatology image objects that contain a predefined set of metadata elements like the patient name and identifier.  Second, it is advantageous to be consistent with the rest of the digital medical imaging community in order to take advantage of existing interoperability opportunities (e.g., Integrating the Healthcare Enterprise).

A DICOM image object is composed of a set of metadata elements followed by the image, and is processed (that is, created, transmitted, stored, reviewed, archived, etc.) as a single entity.  The metadata consist of a specific set of data elements that are defined in the DICOM Standard for a clinical discipline and an acquisition technology.  DICOM was originally developed for radiology and has been very successful there.  It is now being used in other clinical specialties like cardiology, dentistry, ophthalmology, endoscopy, and pathology.

Teledermatology provides an opportunity for DICOM to be used in the “low tech, low cost” clinical settings, where there may be no healthcare system infrastructure at all.  Teledermatology is generally practiced by acquiring images with a digital camera, downloading them to a personal computer (PC) or telemedicine workstation, attaching them to an email message, and sending them to the dermatology consultant.  DICOM can be used to standardize the image acquisition process, the store and forward process, and the reading review process, and to do so at a low cost.

Acquisition Software

A DICOM image acquisition software package needs to be loaded onto the PC that is going to be used to obtain patient and study identification information, receive the images from the digital camera, create DICOM objects from the metadata and the raw images, and send them to the consulting service.

The DICOM metadata contained in every image object includes patient and study identification information as well as clinical data.  This is usually obtained by the DICOM software at the beginning of the image acquisition session, although some image specific information (for example, body site or laterality), acquisition parameters (for example, type of camera and setting), and comments (for example, “Patient not cooperative”) may be input during the imaging process. 

Table 1 shows the set of data elements representative of the types of data that can be acquired prior to the imaging process.

Table 1: The set of data elements representative of the types of data that can be acquired prior to the imaging process.

Values for some of these data elements, like the institution and referring physician information, can be set via site-configurable options.  Other data elements, like the patient and study information, need to be acquired on a study-by-study basis.  There are two ways to do this.  If the clinic has an order entry application as part of an Electronic Health Record (HER), it may be possible to electronically transfer this information to the image acquisition system using the DICOM Modality Worklist service. In the absence of such facilities, the data needs to be entered manually.

Once this information is obtained by the DICOM software image acquisition can be performed.  As each image is acquired, additional information about the body site may need to be entered.  After the images are acquired, they are joined with their corresponding metadata and are formed into DICOM objects. These DICOM objects are then sent to the consulting service.

Transferring the DICOM Objects

There are three different ways to send DICOM objects, depending upon the technical capabilities of the consulting service.

If Internet connectivity does not exit, the DICOM objects can be written onto CD or DVD and sent to the consultant via physical mail.  The IHE Portable Data for Imaging (PDI) integration profile specifies the im