JMIR Publications

ABSTRACT

Background:

The large and growing number of melanoma patients who need long term surveillance increasingly exceeds capacity of the dermatology workforce, particularly outside of metropolitan areas. Digital technologies that enable patients to do skin self-examination and send dermoscopic images of lesions of concern to a dermatologist (mobile teledermoscopy) are one potential solution. If these technologies and the remote delivery of melanoma surveillance are to be incorporated into routine clinical practice, they need to be accepted by clinicians providing melanoma care (e.g., dermatologists and general practitioners (GPs)).

Objective:

To explore perceptions of potential benefits and harms of mobile teledermoscopy, and experiences with this technology, among clinicians participating in a pilot randomised controlled trial (RCT) of patient-led melanoma surveillance.

Methods:

This qualitative study was nested within a pilot RCT conducted at dermatologist- and skin specialist GP-led melanoma clinics in New South Wales, Australia. We conducted semi-structured interviews with 8 of the total 11 clinicians who were involved in the trial: 4 dermatologists (3 provided teledermatology, 2 were treating clinicians), 1 surgical oncologist, and 3 GPs with qualifications in skin cancer screening (the remaining 3 GPs declined interview). Thematic analysis was used to analyse the data with reference to concepts ‘medical overuse’ and ‘high-value care’.

Results:

Clinicians identified several potential benefits, including increased access to dermatology services, earlier detection of melanomas, reassurance for patients between scheduled visits, and a reduction in unnecessary clinic visits. However, they also identified some potential concerns around use of the technology and remote monitoring that could result in diagnostic uncertainty. These included poor image quality, difficulty making assessments from a 2D digital image (even if good quality), insufficient clinical history provided, and concern that suspicious lesions may have been missed by the patient. Clinicians thought that uncertainty arising from these concerns, together with perceived potential medico-legal consequences from missing a diagnosis, might lead to increases in unnecessary clinic visits and procedures. Strategies suggested for achieving high-value care included managing clinical uncertainty in order to decrease the potential for medical overuse, and by ensuring optimal placement of patient-led teledermoscopy within existing clinical care pathways to increase the potential for benefits.

Conclusions:

Clinicians were enthusiastic about the potential and experienced benefits of mobile teledermoscopy; however, managing clinical uncertainty will be necessary to achieve these benefits in clinical care outside of trial contexts, and to minimise potential harms from medical overuse.