Evaluation Criteria for Mobile Teledermatology Applications and Comparison of Major Mobile Teledermatology Applications

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1 Telemedicine and e-health Telemedicine and e-health Manuscript Central: Evaluation Criteria for Mobile Teledermatology Applications and Comparison of Major Mobile Teledermatology Applications Journal: Telemedicine and e-health Manuscript ID: TMJ-0-0.R Manuscript Type: Communication Report Date Submitted by the Author: n/a Complete List of Authors: Ho, Baran; University of California, San Diego, School of Medicine Lee, Michael; University of California, Davis, Dermatology Armstrong, April; University of California Davis, Dermatology Keyword: Teledermatology, Telecommunications, e-health, Commercial Telemedicine, Technology Mary Ann Liebert, Inc., 0 Huguenot Street, New Rochelle, NY 00

2 Page of Telemedicine and e-health Evaluation Criteria for Mobile Teledermatology Applications and Comparison of Major Mobile Teledermatology Applications Authors: Baran Ho, BS, Michael Lee, April W. Armstrong MD MPH, Affiliations: University of California San Diego School of Medicine, San Diego, CA University of California Davis, Department of Dermatology, Sacramento, CA Running title: Evaluation Criteria for Mobile Telederm Applications Corresponding Author: April W. Armstrong, MD, MPH Assistant Professor of Dermatology Director, Dermatology Clinical Research Unit Director, Teledermatology Program Department of Dermatology University of California Davis Health System 0 C Street, Suite 00 Sacramento, CA aprilarmstrong@post.harvard.edu Telephone: () -0 Fax: () -0 Word count (abstract): words Word count (text): 000 words Figures: Tables: References: Funding sources: None. Financial disclosures: None reported. Conflict of interest: The authors declare no relevant conflict of interest pertaining to this manuscript. Prior presentation: This manuscript has not been previously published and is not under consideration in the same or substantially similar form in any other peer-reviewed media. Mary Ann Liebert, Inc., 0 Huguenot Street, New Rochelle, NY 00

3 Telemedicine and e-health Page of Abstract Background: Mobile teledermatology applications have enabled increased patient access to dermatologic care. For groups interested in starting a mobile teledermatology program, selection of the appropriate application can be challenging. Having pre-tested evaluation criteria allows for efficient, systematic assessment of mobile teledermatology applications and identification of features important for comparison. Introduction: The primary aim is to determine a framework for evaluation of mobile teledermatology applications and to compare two major mobile teledermatology applications available in the United States using the proposed criteria. Materials and Methods: We incorporated previous teledermatology application evaluation criteria and developed new evaluation criteria to reflect matters specific to the mobile platform. Through a systematic search, we identified two publicly available mobile teledermatology applications in the United States and applied the evaluation criteria. Results: The -point evaluation criteria encompass three major domains: () technical specifications, () user experience and workflow, and () integration and scalability. The evaluation criteria provided an effective way of assessing the two mobile teledermatology applications. Both AccessDerm v.0 and ClickMedix v. were capable of managing consultations. These applications adopted different approaches to balancing image quality versus data transmission, managing follow-up patients, and enabling dialogue between providers. Mary Ann Liebert, Inc., 0 Huguenot Street, New Rochelle, NY 00

4 Page of Telemedicine and e-health Discussion: Mobile teledermatology provides convenient and scalable means of providing specialty care. The creation of mobile application evaluation criteria offers a useful guide for assessing future mobile applications. Introduction Teledermatology entails the use of communication technology to provide dermatologic care. Implementation of teledermatology has been successful in improving access to dermatologic care and patient outcomes, while maintaining diagnostic accuracy and concordance when compared to conventional in-person dermatology. - As mobile technology continues to mature, clinicians have found novel applications of teledermatology through the mobile platform., Studies have shown mobile teledermatology to be valuable in providing more immediate connection between patients and providers, more convenient upload and transmission of images and clinical data, and potentially more rapid response time due to immediate availability of the clinical information. - There are relatively few comprehensive, commercially available mobile teledermatology applications. For groups interested in starting a mobile teledermatology program, selection of the appropriate application can be challenging. Having pre-tested evaluation criteria allows for efficient, systematic assessment of mobile teledermatology applications and identification of features important for comparison. While applications evolve constantly, criteria that are based on clinical relevance, efficiency, and usability will continue to be important for assessing future applications. Mary Ann Liebert, Inc., 0 Huguenot Street, New Rochelle, NY 00

5 Telemedicine and e-health Page of The primary aims of this study are to determine evaluation criteria of mobile teledermatology applications and to compare the major mobile teledermatology applications in the United States. We anticipate that the results from this study will help users determine important parameters in choosing the appropriate mobile application for clinical use. Materials and Methods Selection of Mobile Teledermatology Applications We conducted a search of the ios (Apple Inc.) and Android (Google Inc.) application markets in the United States as of September, 0 to identify potential mobile teledermatology applications. Applications with a niche focus (e.g. moles only) or did not allow for consultations between physicians were excluded. This yielded two major, commercially available mobile teledermatology applications: AccessDerm (v.0, Vignet Corp., McLean, Virginia, USA) and ClickMedix (v., ClickMedix LLC., Rockville, Maryland, USA). Both applications meet the American Telemedicine Association Standard for Teledermatology Applications. Evaluation Process For each application, we developed and submitted ten identical cases. We applied a set of a priori pretested criteria that were originally developed for comparison of teledermatology applications on non-mobile platforms. Briefly, these criteria were established through a query of the American Telemedicine Association Teledermatology Special Interest Group and the American Academy of Dermatology Telemedicine Task Force. After seven iterations, we developed new evaluation criteria to reflect matters specific to the mobile platform. The Mary Ann Liebert, Inc., 0 Huguenot Street, New Rochelle, NY 00

6 Page of Telemedicine and e-health evaluations were performed by a multidisciplinary group of dermatologists, information technicians, and potential users. In-depth interviews with the developers were conducted to gain further insight into application capabilities. RESULTS Evaluation Criteria for Mobile Teledermatology Applications The -point evaluation criteria encompass three major domains: () technical specifications, () user experience and workflow, and () integration and scalability (Table ). Technical specifications entail the types of mobile platforms supported by the application and how the application handles information security, transmission of media, and data storage. These factors are especially important in mobile applications, given the need for multiplatform communication and the concern for information security over a telecommunication network. User experience and workflow cover the user-friendliness of the application interface as well as how the application facilitates communication between referring and consultant providers. In addition, how the application addresses follow-up patient care is also considered. These user experience and workflow features will be central to provider satisfaction. Integration and scalability addresses the degree to which the mobile application can communicate with or be integrated into existing electronic medical record and billing systems. In addition, responsiveness of the application to accommodate significant increases in consult Mary Ann Liebert, Inc., 0 Huguenot Street, New Rochelle, NY 00

7 Telemedicine and e-health Page of volume is relevant. Finally, cost-effectiveness of the mobile application relative to its capabilities is important to consider. Application of Mobile Teledermatology Criteria to Existing Applications We summarize the results of our evaluation in Table. In this section we highlight the aspects of our evaluation most likely to be relevant for healthcare professionals when selecting a mobile teledermatology application. The AccessDerm v.0 application s strengths lie in accessibility and ease of use. The application is supported on multiple platforms, improving accessibility. The application also supports push notifications and to facilitate communication between referring providers and consultant dermatologists. The user interface is simple and streamlined, which makes it easier for providers to learn how to use the application (Fig. A,B). The ClickMedix v. application offers several notable unique features in addition to its intuitive workflow and layout (Fig. A). The ability to tag a picture to a body diagram allows for easy labeling of patient images (Fig. B). The built in camera tutorial and image feedback field give active instruction and feedback for referring providers to improve upon image acquisition skills. Lastly, the web interface offers built-in analytic tools that allow for a very comprehensive and informative method for viewing data. Discussion Mary Ann Liebert, Inc., 0 Huguenot Street, New Rochelle, NY 00

8 Page of Telemedicine and e-health Teledermatology continues to be an active and growing field of practice in the United States. The use of mobile applications in teledermatology will expand healthcare access and possibly provide improved patient outcomes. - Therefore, the selection of a secure, user-friendly, and robust mobile teledermatology application is essential. The mobile teledermatology application evaluation criteria presented here offer an efficient and systematic approach to the selection process. Together, these criteria address technology factors, provider priorities, and workflow and communication preferences. Individual criteria within these categories offer an infrastructure for further assessment of mobile teledermatology applications. A potential limitation to mobile teledermatology evaluation criteria is the pace of technological advancement. As future applications are developed, new technology may enable features that are not specifically addressed in our evaluation criteria. A challenge in the evaluation was to maintain stable versions of each application, as software updates can frequently change application capabilities. This evaluation revealed several important areas of further development in mobile applications for teledermatology: () increased integration with existing systems of electronic medical records, () availability of built-in reimbursement and billing capability, and () mechanisms for easy recall of previous consults on the same patient for longitudinal follow-up. As mobile technology continues to progress at a rapid pace, comparative analysis and user feedback will lead to further improvements in the field of mobile teledermatology technology. Mary Ann Liebert, Inc., 0 Huguenot Street, New Rochelle, NY 00,

9 Telemedicine and e-health Page of Acknowledgements The authors thank developers Dave Klein and Praduman Jain of Vignet Corp. and Ting Shih of ClickMedix, LLC for communicating with the research team regarding the capabilities and functionalities of their applications and allowing us to trial demo versions of their platforms. Author Disclosure Statement No competing financial interests exist. References. Pak H, Edison K., Whited J. Teledermatology: A user's guide. New York, NY: Cambridge Press, 00.. Warshaw EM, Hillman YJ, Greer NL, et al. Teledermatology for diagnosis and management of skin conditions: a systematic review. Journal of the American Academy of Dermatology. 0;:-.. Hsiao JL, Oh DH. The impact of store-and-forward teledermatology on skin cancer diagnosis and treatment. Journal of the American Academy of Dermatology. 00;:0-.. Armstrong AW, Kwong MW, Ledo L, et al. Practice models and challenges in teledermatology: a study of collective experiences from teledermatologists. PloS one. 0;:e.. Edison KE, Ward DS, Dyer JA, et al. Diagnosis, diagnostic confidence, and management concordance in live-interactive and store-and-forward teledermatology compared to inperson examination. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 00;:-.. Barnard CM, Goldyne ME. Evaluation of an asynchronous teleconsultation system for diagnosis of skin cancer and other skin diseases. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 000;:-.. Lamel SA, Haldeman KM, Ely H, et al. Application of mobile teledermatology for skin cancer screening. Journal of the American Academy of Dermatology. 0.. Fruhauf J, Hofman-Wellenhof R, Kovarik C, et al. Mobile Teledermatology in Sub- Saharan Africa: A Useful Tool in Supporting Health Workers in Low-resource Centres. Acta Derm Venereol. 0. Mary Ann Liebert, Inc., 0 Huguenot Street, New Rochelle, NY 00

10 Page of Telemedicine and e-health Hayn D, Koller S, Hofmann-Wellenhof R, et al. Mobile phone-based teledermatologic compliance management - preliminary results of the TELECOMP study. Stud Health Technol Inform. 00;0:-. 0. Massone C, Hofmann-Wellenhof R, Ahlgrimm-Siess V, et al. Melanoma screening with cellular phones. PloS one. 00;:e.. Tran K, Ayad M, Weinberg J, et al. Mobile teledermatology in the developing world: implications of a feasibility study on 0 Egyptian patients with common skin diseases. Journal of the American Academy of Dermatology. 0;:0-0.. Azfar RS, Weinberg JL, Cavric G, et al. HIV-positive patients in Botswana state that mobile teledermatology is an acceptable method for receiving dermatology care. Journal of telemedicine and telecare. 0;:-0.. Krupinski E, Burdick A, Pak H, et al. American Telemedicine Association's Practice Guidelines for Teledermatology. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 00;:-0.. Armstrong AW, Sanders C, Farbstein AD, et al. Evaluation and comparison of store-andforward teledermatology applications. Telemedicine journal and e-health : the official journal of the American Telemedicine Association. 00;:-.. Massone C, Wurm EM, Hofmann-Wellenhof R, Soyer HP. Teledermatology: an update. Seminars in cutaneous medicine and surgery. 00;:0-0.. Armstrong AW, Wu J, Kovarik CL, et al. State of teledermatology programs in the United States. Journal of the American Academy of Dermatology. 0.. Arsand E, Tatara N, Ostengen G, Hartvigsen G. Mobile phone-based self-management tools for type diabetes: the few touch application. J Diabetes Sci Technol. 00;:-.. Braun RP, Vecchietti JL, Thomas L, et al. Telemedical wound care using a new generation of mobile telephones: a feasibility study. Archives of dermatology. 00;:-.. Kroemer S, Fruhauf J, Campbell TM, et al. Mobile teledermatology for skin tumour screening: diagnostic accuracy of clinical and dermoscopic image tele-evaluation using cellular phones. Br J Dermatol. 0;:-. Please direct reprint requests to: April W. Armstrong, MD, MPH Department of Dermatology University of California Davis Health System 0 C Street, Suite 00 Sacramento, CA Mary Ann Liebert, Inc., 0 Huguenot Street, New Rochelle, NY 00

11 Telemedicine and e-health Page 0 of Table. Evaluation Criteria for Mobile Teledermatology Applications Evaluation Criteria Technical specifications Description Supported mobile devices Types of mobile devices that support the application; the ability to and desktop capability display and manage information on a computer web application. Information security Data-level, application-level, network-level, and host-level security. HIPAA compliance. Storage and backup Local storage versus cloud-based storage; availability of backup systems. Images Resolution, file size, and number of images that can be uploaded per case to the mobile device; compressibility of images. User experience and workflow User interface Work process from referring provider Work process from consulting dermatologist Care of follow-up patients Communication among providers Integration and scalability Electronic health record integration Billing integration Scalability Cost-effectiveness User-friendliness, accessibility, and intuitiveness of the application. Customizability of workflow; relevance of queried clinical information; ease of data entry; integration of image capture and editing features; auto-detection of image quality; transmission of images and clinical history; ability to direct cases to either a specific consultant or to a pool of consultants. Customizability of workflow; customizability of response templates; ease of data entry; transmission of recommendations. Ability to identify follow-up patients and provide longitudinal care; ability to view previous images and recommendations. Communication between referring providers and dermatologists; communication among dermatologists for second-opinion; communication between dermatology trainees and faculty. Integration of existing electronic health records systems and applications. Ability to capture and/or process billing information directly to a third-party payer. Ability to adapt to high consult volume and multiple users. Consider set-up and user costs in relationship to application capabilities. Mary Ann Liebert, Inc., 0 Huguenot Street, New Rochelle, NY 00

12 Page of Telemedicine and e-health Table. Summary of Feature Comparison Between Major Mobile Teledermatology Applications Using Evaluation Criteria Technical specifications User experience and workflow Evaluation Criteria AccessDerm v.0 ClickMedix v. Supported mobile ios. or above (iphone and ios.0 or above (iphone and devices and desktop ipad), Android OS. or above ipad), Android OS. or above capability (phone and tablet), Windows (phone and tablet). Application Phone. Application is is accessible on the web. accessible on the web. Information security Multi-layer implementation of Uses multifactor authentication security with user and encrypts the data during ondevice authentication, access control, data entry, data host-level antivirus and network transmission, post data control. Data are encrypted. transmission, and database Auto-logout occurs after encryption when data is at rest. minutes of inactivity on web Auto-logout occurs after 0 application. HIPAA compliant minutes of inactivity on web across broadband spectrum. application. HIPAA compliant across broadband spectrum. Storage and backup No data are stored locally once No data are stored locally once case is submitted. Data are case is submitted. Data are stored in servers in a DC data stored on private virtual servers center and replicated for and replicated for disaster or disaster or outage scenarios. outage scenarios. Images Image size is compressed to Recommend using camera megabytes prior to upload. phones with megapixels. Application can allow for Image resolution is based on images from megapixel to phone camera capability and megapixels. User may submit not limited by application. User four images. The compression may submit up to 0 images rate and number of images (iphone) or unlimited images attached may be customized on (Android). The number of request. Current deployment images attached may be does not support DICOM customized on request. DICOM compliant images. integration available through third party application. User interface Streamlined interface with Clean intuitive workflow with ability to send SMS, push customizable options. notifications, and s for case alerts and user updates. Work process from Patient clinical history is Patient clinical history is referring provider submitted via a preset template. submitted via a customizable Template uses free text boxes template. Default template and toggle buttons. Images can composed of free text boxes be captured directly to and radio buttons. Images can application or uploaded from be captured directly to Mary Ann Liebert, Inc., 0 Huguenot Street, New Rochelle, NY 00

13 Telemedicine and e-health Page of Integration and scalability Work process from consulting dermatologist Care of follow-up patients Communication among providers Electronic health record integration Billing integration Scalability phone. Cases are submitted to a pool of consultants. Claimed cases are locked and cannot be viewed by other providers. Preset response template offers two free text boxes for diagnosis and treatment. Can view previously submitted images and recommendations under case history. Referring provider and consultant may add comments to a case to communicate in a chat format. Cases may not be forwarded to other consultant providers. Resident physicians may accept cases and forward to attending physicians for review. Compatible with Greenway and Nextgen electronic health records using web application. Billing function requires customization. Scalable. Workflow can be customized to suit practice. Web-based administrator portal enables account management, case management, and creation of groups. application or uploaded from phone. Images can be tagged to body location. Cases are submitted to a single consultant or a pool of consultants. Claimed cases are locked but can still be viewed by other providers. Preset response template offers several free text boxes and option to indicate photo quality. Response forms can be customized to include additional fields. Can use previously assigned patient ID number to create follow up case. Search function allows user to query all fields to view previous cases. Referring provider and consultant may add comments to a case. Cases may be forwarded to other consultant providers who can add comments. Resident physicians may accept cases and forward to attending physicians for review. Compatible with Phyaura, Practice Fusion, and eclinicalworks electronic health record systems using web application. Integration with electronic health records provides billing function. Can print billing documents directly from application. Scalable. Workflow can be customized to suit practice. Web-based administrator portal enables account management, case management, and creation of groups. Mary Ann Liebert, Inc., 0 Huguenot Street, New Rochelle, NY 00

14 Page of Telemedicine and e-health Fig : A) Home screen of AccessDerm v.0 from primary care provider perspective B) Active drop down free text box after selecting Yes toggle button Fig : A) ClickMedix v. Summary screen before submitting case B) Ability to tag pictures to body location Mary Ann Liebert, Inc., 0 Huguenot Street, New Rochelle, NY 00

15 Telemedicine and e-health Page of Home screen of AccessDerm v.0 from primary care provider perspective xmm ( x DPI) Mary Ann Liebert, Inc., 0 Huguenot Street, New Rochelle, NY 00

16 Page of Telemedicine and e-health Active drop down free text box after selecting Yes toggle button xmm ( x DPI) Mary Ann Liebert, Inc., 0 Huguenot Street, New Rochelle, NY 00

17 Telemedicine and e-health Page of ClickMedix v. Summary screen before submitting case xmm ( x DPI) Mary Ann Liebert, Inc., 0 Huguenot Street, New Rochelle, NY 00

18 Page of Telemedicine and e-health Ability to tag pictures to body location xmm ( x DPI) Mary Ann Liebert, Inc., 0 Huguenot Street, New Rochelle, NY 00