Comparative effectiveness study of face-to-face and teledermatology workflows for diagnosing skin cancer

Published:February 07, 2019DOI:


      The effectiveness and value of teledermatology and face-to-face workflows for diagnosing lesions are not adequately understood.


      We compared the risks of biopsy and cancer diagnosis among 2 face-to-face workflows (direct referral and roving dermatologist) and 4 teledermatology workflows.


      Retrospective study of 59,279 primary care patients presenting with a lesion from January through June 2017.


      One teledermatology workflow achieved high-resolution images with use of a dermatoscope-fitted digital camera, a picture archiving and communication system, and image retrieval to a large computer monitor (in contrast to a smartphone screen). Compared with direct referral, this workflow was associated with a 9% greater probability of cancer detection (95% confidence interval [CI], 2%-16%), a 4% lower probability of biopsy (relative risk, 0.96; 95% CI, 0.93-0.99), and 39% fewer face-to-face visits (relative risk, 0.61; 95% CI, 0.57-0.65). Other workflows were less effective.


      Differing proficiencies across teledermatology workflows and selection of patients for direct referral could have caused bias.


      Implementation is critical to the effectiveness of teledermatology.

      Key words

      Abbreviations used:

      CI (confidence interval), EMR (electronic medical record), RR (relative risk)
      To read this article in full you will need to make a payment
      AAD Member Login
      AAD Members, full access to the journal is a member benefit. Use your society credentials to access all journal content and features
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Purchase one-time access:

      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Warshaw E.
        • Greer N.
        • Hillman Y.
        • et al.
        Teledermatology for Diagnosis and Management of Skin Conditions: A Systematic Review of the Evidence.
        ([Internet]) Department of Veterans Affairs (US), Washington (DC)2010 (Available from)
        • Armstrong A.W.
        • Wu J.
        • Kovarik C.L.
        • et al.
        State of teledermatology programs in the United States.
        J Am Acad Dermatol. 2012; 67: 939-944
        • Bashshur R.L.
        • Shannon G.W.
        • Tejasvi T.
        • Kvedar J.C.
        • Gates M.
        The empirical foundations of teledermatology: a review of the research evidence.
        Telemed J E Health. 2015; 21: 953-979
        • Finnane A.
        • Dallest K.
        • Janda M.
        • Soyer H.P.
        Teledermatology for the diagnosis and management of skin cancer: a systematic review.
        JAMA Dermatol. 2017; 153: 319-327
        • Ray G.T.
        • Kulldorff M.M.
        • Asgari M.M.
        Geographic clusters of basal cell carcinoma in a northern California health plan population.
        JAMA Dermatol. 2016; 152: 1218-1224
        • Philips
        PACS systems and web view connectivity; IHE integration statements.
        • Imprivata
        The CIO's guide to HIPAA compliant text messaging.
        • Google Play
        Epic Haiku.
        • Asgari M.M.
        • Tang J.
        • Epstein Jr., E.H.
        • et al.
        Statin use and risk of basal cell carcinoma.
        J Am Acad Dermatol. 2009; 61: 66-72
        • Asgari M.M.
        • Eide M.J.
        • Warton E.M.
        • Fletcher S.W.
        Validation of a large basal cell carcinoma registry.
        J Registry Manag. 2013; 40: 65-69
        • Eide M.J.
        • Krajenta R.
        • Johnson D.
        • et al.
        Identification of patients with nonmelanoma skin cancer using health maintenance organization claims data.
        Am J Epidemiol. 2010; 171: 123-128
        • Silverberg M.J.
        • Leyden W.
        • Warton E.M.
        • Quesenberry Jr., C.P.
        • Engels E.A.
        • Asgari M.M.
        HIV infection status, immunodeficiency, and the incidence of non-melanoma skin cancer.
        J Natl Cancer Inst. 2013; 105: 350-360
        • Fitzmaurice G.M.
        • Laird Nan M.
        • Ware James H.
        Applied Longitudinal Analysis.
        2nd ed. John Wiley & Sons, 2012
        • Laupacis A.
        • Sackett D.L.
        • Roberts R.S.
        AN assessment of clinical useful measures of the consequences of treatment.
        N Engl J Med. 1988; 318: 1728-1733
        • Castro D.A.
        • Naqvi A.A.
        • Manson D.
        • Flavin M.P.
        • VanDenKerkhof E.
        • Soboleski D.
        Novel method to improve radiologist agreement in interpretation of serial chest radiographs in the ICU.
        J Clin Imaging Sci. 2015; 5: 39
        • Qureshi A.A.
        • Brandling-Bennett H.A.
        • Giberti S.
        • McClure D.
        • Halpern E.F.
        • Kvedar J.C.
        Evaluation of digital skin images submitted by patients who received practical training or an online tutorial.
        J Telemed Telecare. 2006; 12: 79-82
        • Warshaw E.M.
        • Gravely A.A.
        • Nelson D.B.
        Reliability of store and forward teledermatology for skin neoplasms.
        J Am Acad Dermatol. 2015; 72: 426-435
        • Pak H.
        • Triplett C.
        • Lindquist J.
        • Grambow S.
        • Whited J.
        Store-and-forward teledermatology results in similar clinical outcomes to conventional clinic-based care.
        J Telemed Telecare. 2007; 13: 26-30
        • Watson A.
        • Bergman H.
        • Williams C.
        • Kvedar J.
        A randomized trial to evaluate the efficacy of online follow-up visits in the management of acne.
        Arch Dermatol. 2010; 146: 406-411
        • Ferrandiz L.
        • Ruiz de Casas A.
        • Martin Gutierrez F.
        • et al.
        Effect of teledermatology on the prognosis of patients with cutaneous melanoma.
        Arch Dermatol. 2012; 148: 1025-1028
        • Eastman K.
        • Lutton M.
        • Raugi G.T.
        • et al.
        A teledermatology care management protocol for tracking completion of teledermatology recommendations.
        J Telederm Telecare. 2012; 18: 374-378
        • McFarland L.
        • Raugi G.
        • Taylor L.
        • Reiber G.
        Implementation of an education and skills programme in a teledermatology project for rural veterans.
        J Telemed Telecare. 2012; 18: 66-71
        • Snoswell C.
        • Finnane A.
        • Janda M.
        • Soyer H.P.
        • Whitty J.A.
        Cost-effectiveness of store-and-forward teledermatology: a systematic review.
        JAMA Dermatol. 2016; 152: 702-708
        • Tensen E.
        • van der Heijden J.P.
        • Jaspers M.W.
        • Witkamp L.
        Two decades of teledermatology: current status and integration in national healthcare systems.
        Curr Dermatol Rep. 2016; 5: 96-104
        • Livingstone J.
        • Solomon J.
        An assessment of the cost-effectiveness, safety of referral and patient satisfaction of a general practice teledermatology service.
        London J Prim Care (Abingdon). 2015; 7: 31-35
        • Kahn E.
        • Sossong S.
        • Goh A.
        • Carpenter D.
        • Goldstein S.
        Evaluation of skin cancer in Northern California Kaiser Permanente's store-and-forward teledermatology referral program.
        Telemed J E Health. 2013; 19: 780-785
        • Datta S.K.
        • Warshaw E.M.
        • Edison K.E.
        • et al.
        Cost and utility analysis of a store-and-forward teledermatology referral system: a randomized clinical trial.
        JAMA Dermatol. 2015; 151: 1323-1329
        • Armstrong A.W.
        • Kwong M.W.
        • Ledo L.
        • Nesbitt T.S.
        • Shewry S.L.
        Practice models and challenges in teledermatology: a study of collective experiences from teledermatologists.
        PLoS One. 2011; 6: e28687