JMIR Publications

ABSTRACT

Background:

Store-and-forward (SAF) teledermatology can improve access to timely and cost-effective dermatologic care. Previous research has found high diagnostic concordance rates between SAF teledermatology and face-to-face clinical diagnosis, but none have used specific cases to illustrate factors contributing to diagnostic discordance.

Objective:

To identify and illustrate characteristics that may have contributed to diagnostic discordance between store-and-forward teledermatology and in-person clinical diagnosis in a series of patients.

Methods:

We identified seven cases of diagnostic discordance between teledermatology and in-person visits, where the favored diagnosis of the in-person dermatologist was not included in the differential diagnosis formulated by the teledermatologist. Cases were identified from a previously published retrospective chart review of all SAF teledermatology consultations which was previously performed at an academic community health care system in the greater Boston area, Massachusetts from January 1 2014, through December 31, 2017 (n= 3,285) which included a subanalysis of 340 teledermatology visits.[14] In 99 of these cases, patients completed an in-person dermatology appointment after their teledermatology consultation. We identified 7 cases where diagnostic discordance occurred and included them in our case series.

Results:

Factors contributing to diagnostic discordance between SAF teledermatology consultations and in-person visits included poor image quality, inability to evaluate textural characteristics, diagnostic uncertainty due to atypical presentations, and evolution in appearance of skin conditions over time.

Conclusions:

We identified multiple factors that contributed to diagnostic discordance including poor image quality, atypical presentations, inability to evaluate textural characteristics, and changing appearance of skin conditions over time. Recognition and mitigation of these factors when possible, may help to improve diagnostic accuracy and reduce the likelihood of misdiagnosis. Ongoing communication with referring providers and robust systems for in-person follow-up, may be helpful in reducing the risk of misdiagnosis due to inherent limitations of teledermatology services.