iProceedings

Image Quality Assessment Using a Convolutional Neural Network for Clinical Skin Images

2023-08-31T10:31:27-04:00

Background: The quality of the images received for teledermatology evaluation is often suboptimal, with up to 50% of patients providing images that are poorly lit, off-center, or blurry. To ensure a similar level of care to in-person consultations, high-quality images are essential. Objective: The aim of this study is to develop an image quality analysis tool to assess patient- and primary care physician (PCP)–derived images using a deep learning model leveraging multiple instance learning and ordinal regression for model predictions. Methods: The data set used for this study was acquired from patient-derived images submitted to the Department of Dermatology, Duke University, between August 21, 2018, and December 31, 2019, and PCP-derived images between March 1, 2021, and June 30, 2022. Seven dermatology faculty members with a designation of professor, associate professor, and assistant professor evaluated 400 images each, and 2 dermatology residents evaluated 400 images, assuring that each image had 4 different quality labels. We used a pretrained model VGG16 architecture, further fine-tuned by updating weights based on the input data. The images were taken with cell phones (patients) or cameras (PCPs) in RGB scale, with the resolution being 76 pixels per inch for both height and width, and the average pixel size of the image being 2840×2793 (SD 986×983; 1471 inch², SD 707 inch²). The optimal threshold was determined using the Youden index, which represents the best trade-off between sensitivity and specificity and balance the number of true positives and true negatives in the classification results. Once the model predicts the rank, the ordinal labels are transformed to binary labels by using a majority vote as the goal is to distinguish between 2 distinct categories (good vs bad quality) and not predict quality as a continuous variable. Results: Based on the Youden index, we achieved a positive predicted value of 0.906, implying that the model will predict 90% of the good-quality images as such, while 10% of the poor-quality images are predicted as being of good quality to enhance clinical utility, with an area under the receiver operating characteristic curve (AUC) for the test set at 0.885 (95% CI 0.838-0.933) and sensitivity, specificity, and negative predictive value (NPV) of 0.829, 0.784, and 0.645, respectively. Further evaluation on independent validation consisting of 300 images from patients and 150 images from PCPs revealed AUCs of 0.864 (95% CI 0.818-0.909) and 0.902 (95% CI 0.85-0.95), respectively. The sensitivity, specificity, positive predicted value, and NPV for the 300 images were 0.827, 0.800, 0.959, and 0.450, respectively. Conclusions: This study shows a practical approach to improve image quality for clinical decision-making. While patients and PCPs may have to capture additional images (due to lower NPV), this is offset by the reduced workload and improved efficiency of clinical teams due to the receipt of higher-quality images. Additional images can also be useful if all images (good or poor) are transmitted to medical records. Future studies need to focus on real-time clinical validation of our results.

Teledermatology in India During the Peri–COVID-19 Outbreak Period: Advantages, Shortcomings, and Challenges

2023-08-17T10:46:12-04:00

Background: Telemedicine is defined as the use of electronic information and communication technologies for health care professionals to provide care to patients. Although available since the pre–COVID-19 era, a huge surge in teledermatology consultations occurred during the COVID-19 outbreak. As access to health care became limited and difficult due to repeated lockdowns, teledermatology helped us provide health care to our patients. Moreover, as dermatology is a visual field, it was even more suitable for teleconsultations. Objective: The objectives of this study were to investigate the advantages, shortcomings, and challenges of teledermatology in India during the peri–COVID-19 outbreak period. Methods: This was a single-center, retrospective, observational study conducted at a tertiary care hospital in India. Teledermatology consultation data from April 1, 2020, till September 2021 (18 months) were included. All modes, including real-time (RT) video, asynchronous store and forward (SAF), and hybrid, were used to conduct teledermatology consultations. Statistical analyses were performed using SPSS software (IBM Corp). Results: During these 18 months, a total of 4280 patients took teledermatology consultations at our center. The mean age of the patients was 34.19 years, with most of them (36.4%) in the age group of 31-40 years. The patient population comprised a mix of urban (55%) and rural (45%) individuals. Overall, 70% of consultations were conducted in the SAF mode; hybrid mode, 16%; and RT video consultations, 14%. Diagnosis was established in 89.1% of the cases, and the most common diagnosis was superficial fungal infection (28%), followed by eczema (16%) and acne (8.6%). Hospital visits were required in the remaining 10.9% of cases for the following reasons: lack of clear pictures and technical errors (5.57%). Additional diagnostic tests were required in 1.3% of cases, physical examination in 1.05% of cases, and 0.39% of patients had life-threatening conditions requiring hospitalization. The advantages of teledermatology include decreased need for hospital visits among 89.1% of patients, which played a very important role in decreasing overcrowding. Also, this helped us provide expert health care to the rural population of India. Owing to shortcomings including the lack of good-quality pictures (4.2%; more so in SAF teleconsultations) and technical errors (1.37%), teledermatology cannot be used to manage life-threatening conditions (0.39%), and, in particular, RT video consultations are more time-consuming (14%). Challenges faced by dermatologists during teledermatology consultations were mainly operational, such as the lack of good internet access leading to interrupted consultations (1.37%), poor quality of pictures (4.2%), and difficulty in extracting history in cases of SAF consultations. Conclusions: Teledermatology serves as a triage platform and helps reduce hospital visits. It helps to cater to the rural population, which otherwise has limited access to health care. Some technical challenges are the dependence of teledermatology on pictures and information sent by the patient for establishing the diagnosis. Also, sometimes patients faced difficulty in conveying problems clearly to the doctors. Because of the ease and advantages, several dermatologists have continued to use teledermatology along with the physical consultations in the post–COVID-19 era. With a few advancements, teledermatology will certainly remain a successful and useful model for consultations, more so for catering to the population with the lack of access to specialist services.

Surgical Excision Margins in Primary Care and Plastic Surgery for Keratinocytic Cancers Diagnosed via Teledermatology: Retrospective Observational Cross-Sectional Study

2023-08-17T10:45:57-04:00

Background: The incidence of keratinocytic cancers is increasing. In New Zealand, surgical treatment of skin cancers is often undertaken in primary care. In the Waikato district, general practitioners (GPs) are encouraged to confirm diagnoses via teledermatology. Histological examination should confirm clear surgical margins to reduce tumor recurrence. International guidelines recommend a lateral margin of ≥3 mm for basal cell carcinomas (BCCs) and ≥4 mm for squamous cell carcinomas (SCCs). Objective: This study aimed to determine lateral and deep margins in keratinocytic cancer excisions performed by GPs (in a private setting) and plastic surgeons (in a private or public setting) after a teledermatologist had confirmed that excision was necessary. Demographic, clinical, and histological features were recorded. Methods: A retrospective observational cross-sectional study was conducted. The sample in the electronic dermatology referral database included keratinocyte cancers recommended for excision from March to May 2022. Results: Histological reports revealed that excision was complete in 186 of 201 confirmed cases of keratinocyte cancer. The lateral margins of resection were considered in 10 tumors and deep margins in 8 tumors. All incomplete excisions were carried out by GPs, 11 of which were on the head and neck. There were 133 BCCs, 100 of which were excised by a GP, 3 by a private plastic surgeon, and 30 by a public hospital surgeon. In total, 52 BCCs were present on the head and neck (25 excised by GPs, 25 by hospital plastic surgeons, and 2 by private plastic surgeons) and 81 were present on other sites (75 excised by GPs, 5 by hospital plastic surgeons, and 1 by a private plastic surgeon). Lateral margins were considered in 9 cases (of which 5 cases involved head and neck tumors). The minimum distance from the tumor to the lateral margin was <3 mm in 80 tumors: 64 were excised by a GP, 2 by private plastic surgeons, and 14 by hospital plastic surgeons. This distance was ≥3 mm in 44 tumors (27 excised by GPs, 1 by a private plastic surgeon, and 16 by hospital plastic surgeons). These data show significant adherence to surgical margin recommendations among plastic surgeons compared to that among GPs (odds ratio 2.873, CI 1.274-6.477; P=.009). There were 68 SCCs: 57 were excised by a GP, 2 by a private plastic surgeon, and 9 by a public hospital surgeon. In total, 21 SCCs were on the head and neck (14 excised by GPs, 6 by hospital plastic surgeons, and 1 by a private plastic surgeon) and 47 were on other sites (43 excised by GPs, 3 by hospital plastic surgeons, and 1 by a private plastic surgeon). Lateral margins were considered in 1 head and neck SCC case and were not reported in others. The minimum distance from the tumor to the lateral margin was <4 mm in 35 cases: 31 were excised by a GP, 1 by a private plastic surgeon, and 3 by a hospital plastic surgeon. This distance was ≥4 mm in 31 cases (24 excised by GPs, 1 by a private plastic surgeon, and 6 by hospital plastic surgeons). These data do not show significant difference in adherence to surgical margin recommendations between GPs and plastic surgeons (P>.05). Conclusions: Complete resection reduces the risk of recurrence of keratinocytic tumors. GPs in our study were less likely than specialist surgeons to respect surgical margin recommendations established in international guidelines for managing keratinocytic cancer.

The Effectiveness of Blended Learning for Dermatology Undergraduate Medical Students

2023-08-01T10:46:38-04:00

Background: Novel internet-based applications and associated technologies have influenced all aspects of our society, ranging from areas of commerce and business to entertainment and health care. Education is no exception. In this context, this study was designed to evaluate the impact of a dermatology e-learning program on the academic performance of medical students. Objective: We aimed to develop a dermatology blended learning course for undergraduate medical students and compare the knowledge gained by students who took this course to those who attended traditional classes. Methods: This prospective study evaluated the performance of fourth-semester medical students from the Federal University of Bahia, Brazil. A total of 129 students were selected and divided into 2 groups. The first group (n=57) attended traditional classes and used printed material (books and handouts). The second group (n=72) took our e-learning course and used an e-book as a supplement in a hybrid setting comprising online plus traditional learning. Each course was evaluated with multiple-choice, paper-based tests that were administered at the beginning and end of the course. Results: Although the precourse tests did not show any difference between the traditional and hybrid groups (mean 2.74, SD 1.25 vs mean 3.2, SD 1.22), students attending the hybrid course had better final term grades (mean 8.18, SD 1.26) than those who attended traditional classes (mean 7.11, SD 1.04). This difference was statistically significant (P<.05). Conclusions: The results suggest that the performance of undergraduate students who took a course supplemented with e-learning material was superior to those who attended a traditional course alone.

Implementation of Teledermatology for Veterans in the United States

2023-08-01T10:46:02-04:00

unstructured: The US Department of Veterans Affairs (VA) has adopted teledermatology, predominantly asynchronous, as an important strategy for improving access to expert skin care for its 9 million enrolled veteran patients. Despite the measurable success of its teledermatology program, one-fifth of all points of care have yet to implement teledermatology. The application of implementation science approaches offers the opportunity to systematically understand the VA’s teledermatology experience to yield insights into and lessons for implementing teledermatology widely as well as locally. Implementation frameworks and theories include the use of the Organizational Readiness for Change instrument as a prognosticator for implementation success, as well as the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework to assess the longitudinal implementation of a teledermatology initiative for rural veterans. Development and implementation of novel technological innovations that introduce new teledermatology workflows into mature teledermatology environments were analyzed during the COVID-19 pandemic.

Effectiveness of Telegenetic Counseling for Patients and Families With Suspected Hereditary Cancer: Systematic Review

2023-06-29T10:45:05-04:00

Background: Telegenetic counseling has attracted attention as a preventive measure against the recent COVID-19 pandemic. This systematic review compared telegenetic counseling using videoconferencing versus face-to-face counseling for hereditary cancer. Objective: This study aimed to evaluate the effectiveness of telegenetic counseling using videoconferencing versus face-to-face counseling for people with suspected hereditary cancer. Methods: A comprehensive literature search was carried out in December 2021 using the databases of the Japan Medical Abstracts Society, PubMed, CINAHL, PsycInfo, EMBASE, and the Cochrane Library. The eligibility criteria were studies in which randomized controlled trials (RCTs) or cluster RCTs were conducted among patients with suspected hereditary cancer and their families, comparing telegenetic counseling using videoconferencing with face-to-face genetic counseling. The Cochrane risk-of-bias tool was used to assess the risk of bias of each RCT study. This study was reported according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) guidelines. Results: Two studies comprising a total of 191 participants were included and used for meta-analysis. Participants were individuals who lived in rural areas or in areas without genetic counselors and were suspected to have breast, colon, ovarian, multiple, or genetic cancer. All outcomes were assessed in only 1 study and their effects could not be discussed explicitly. In one study, there were no significant differences in satisfaction, psychological distress, or a number of genetic tests between face-to-face genetic counseling and telegenetic counseling. The cost per patient for genetic counseling was $106.19 for the telegenetics group and $244.33 for the in-person group. The risk of bias was high in both studies, with a high risk of performance bias, detection bias, and attrition bias. Conclusions: The results of the two RCTs were described qualitatively. However, the evidence is limited because of the small number of RCT studies on telegenetic counseling and the high risk of bias. Further accumulation of studies is needed in the future.

Key Enablers to Boost Digital Health Solutions in Latin America

2023-06-28T10:45:04-04:00

Background: COVID-19 has exposed the fragility of global health systems. However, the pandemic is perceived to have boosted the use of technology and accelerated digital health solutions (DHS). In Latin America, DHS can increase accessibility and provide more efficient health services. Various key players have relevant roles for innovation within the health care systems. For this study, we focused on health-tech start-ups (developers) and health care providers (implementers) who can cocreate and develop new health care solutions. Objective: This research aimed to explore the aspects that boost innovation in the health care ecosystem in Latin America, based on the 5 key aspects of the Innovation Readiness Levels: market, technology, organization, partnerships, and risk. Methods: For this research, a qualitative study was conducted using the 5 key aspects of the Innovation Readiness Levels. Two types of organizations were selected: health-tech start-ups (developers) and health care providers (implementers). A total of 12 professionals from Latin America were interviewed. For each interview, quotes related to the 5 aspects were selected and subclustered to find relationships. Results: Based on the discovered relationships, 7 aspects to boost DHS in Latin America were identified: agility to respond, facilitating collaboration, building and sharing knowledge, creating user-centered solutions, economic resources and sustainability, ease of technological development and adoption, and reaching beyond hospitals. The first 4 aspects could apply to other regions outside Latin America. The last 3 are related to regional challenges in Latin America. Obstacles and calls to action were identified for each aspect. Conclusions: To boost DHS in Latin America, it is necessary to have a complete overview of the patient’s journey and consider all the users involved to understand their needs and identify opportunities to develop new solutions. This will contribute to the improvement of health solutions and patient outreach. Future research is suggested to develop a better understanding of these aspects in the Latin American countries that were not included in this research and to validate whether these are the only key aspects needed.

A Survey of Internet Performance During COVID-19

2023-06-27T10:45:51-04:00

Background: Since the beginning of 2020, many societal systems have been used to extend the health care system, which were not planned for, and as such, there is concern for its collapse. Clearly, the collapse of the health care system, primarily hospitals, has been a key concern, and many initiatives, including lockdown and curfew, were taken to avoid such a collapse. The internet was the key platform used to enable people to work from home, provide remote teaching, conduct meetings on the web, etc. However, when it comes to data communication and processing, the risk of collapse is not the only risk, and maybe not even the biggest one. Many systems were not properly adapted for used in such a hurry, which did not allow time (and concern) for a proper risk and privacy assessment. Objective: This paper presents internet performance statistics and analyzes how this knowledge can be used in future designs of internet-based telemedical solutions. Methods: Statistics regarding traffic increases and security attacks on the internet during 2020 and 2021 were analyzed. Results: The internet did not collapse during the COVID pandemic—as many people had predicted. However, the massive use of the internet, in new innovative ways, created a number of new opportunities for cybersecurity breach. Especially, the use videoconferences enabled made-in-middle attacks, phishing, and other classical breaches in new ways due to insufficient authentication and content encryption. Conclusions: Even though a large amount of experience has been gathered with respect to scaling eHealth systems, a minimum amount of improvement with respect to privacy and security has been identified.

Improving Telehealth Equity in Response to COVID-19 in California: ACTIVATE and Lighthouse

2023-06-27T10:45:37-04:00

Background: In response to the significant stressors on health care delivery created by COVID-19, CITRIS Health and partner organizations developed 2 telehealth solutions through a rapid co-design process: Lighthouse and ACTIVATE. These programs were developed to support providers serving underserved and vulnerable populations who lack the tools and resources to support patients with chronic illness or who are isolated. These challenges were exacerbated by the COVID-19 pandemic, which increased the need for resources to support vulnerable patients who could not come into a clinic in person or were isolated and lacked access to services. ACTIVATE and Lighthouse apply 2 different telehealth strategies to reach vulnerable populations. Objective: This paper presents lessons learned from the design, development, and implementation of 2 innovative telehealth programs developed to improve health care delivery, access to care, digital literacy, and patient outcomes: ACTIVATE and Lighthouse. Methods: ACTIVATE is a comprehensive digital health pathway for community health centers that care for those who are medically underserved. ACTIVATE is an innovative, evidence-based, and sustainable telehealth program, designed to benefit vulnerable populations in rural and agricultural communities in the California Central Valley who experience significant health disparities. Lighthouse focuses on connecting older adults in congregate affordable housing, which are settings where residents are particularly vulnerable to isolation, the lack of health care resources, and limited to no access to the internet. Lighthouse provides digital literacy training as well as access to broadband internet with the goal of increasing communication, engagement, and access to health care. Results: This presentation will discuss successful design and implementation strategies as well as organizational and policy barriers to program operations. Conclusions: In addition to reviewing program and implementation outcomes, strategies for replication and sustainability will be discussed. Although developed in response to COVID-19, the ultimate success of Lighthouse and ACTIVATE is dependent upon its successful scaling beyond the pandemic.

TELEMED: Database on Evidence-Based Telemedicine in a Hospital Setting

2023-06-27T10:45:21-04:00

Background: The use of telemedicine services has increased worldwide during recent years as a result of national strategies for the digitalization of health care and the COVID-19 pandemic. However, health care professionals often express uncertainty regarding the evidence and effectiveness of telemedicine interventions. Therefore, the Centre for Innovative Medical Technology at Odense University Hospital introduced the TELEMED database, an evidence-based telemedicine database. Objective: This study aimed to ensure that hospital managers, health care professionals, and other stakeholders gain access to information about scientific studies of telemedicine interventions and their effectiveness. Methods: The database constitutes a structured literature search in PubMed for randomized controlled trials or controlled trials on the effect of telemedicine for somatic diseases treated at hospitals. The search was conducted by staff members in the Health Technology Assessment unit at the Centre for Innovative Medical Technology. First, identified studies were sorted by screening titles and abstracts and, subsequently, by reading full-text versions. The data extracted from the studies included the setting, intervention, patient group, type of telemedicine, clinical effect, patient perception, and implementation challenges. Finally, the value of each study was assessed with respect to effectiveness. Results: A total of 518 articles were included for data extraction and assessment. The database provides results from 22 different specialties and can be searched using the following criteria: medical specialty, country, technology, clinical effect, patient experience, and economic effect. The database serves as a platform for the dialogue with clinical departments who wish to implement telemedicine services and has a large potential for supporting the digital transformation during COVID-19 as evidence-based information on patient groups, relevant technologies, and their effect is easily accessible. Conclusions: The TELEMED database provides an easily accessible overview of existing evidence-based telemedicine services. The database is freely available and is expected to be continuously improved and broadened over time.