12 CHAPTER 1 TELEDERMATOLOGY: INVOLVED ACTORS AND DELIVERY MODALITIES Teledermatology can be availed by various actors: patients, GPs, and dermatologists (Figure 1.2). In primary teledermatology, the patient directly exchanges photographs taken by himself and information of the skin disorder via a digital consultation request with the healthcare provider (in the Netherlands mostly the GP) [12,46]. In secondary teledermatology, currently the most prevalent used method, the GP seeks TD triage advice or a diagnosis by sending information of the skin disorder and photographs taken by the GP to a TD [12,46]. The aim of this secondary teledermatology is to avoid unnecessary physical patient referrals to the dermatologist or to accelerate patient referrals to the dermatologist for urgent skin lesions that would otherwise not have been directly referred. Tertiary teledermatology involves direct collaboration between dermatologists, for example, a second opinion of a skin lesion or to seek advice from a specialized (academic) dermatologist [12,46,47]. Finally, patientassisted teledermatology concerns direct contact between the patient and the TD such as a follow-up or monitoring [12,46]. Figure 1.2: Involved actors teledermatology [49]. Furthermore, teledermatology can be delivered store-and-forward (asynchronous), real-time (synchronous or live interactive), or hybrid (combination of store-and-forward and real-time) [12,46,48]. Store-and-forward is the commonly used delivery modality of teledermatology in which (high-resolution) digital clinical images are obtained by a GP and exchanged asynchronously between the patient and the GP, between the GP and the TD, or between two dermatologists. Store-and-forward teledermatology consultation is time and space independent. The patient, GP and TD can start or assess the consultation at any time. In contrast, the real-time teledermatology service uses (lowresolution) videoconferencing and facilitates direct interaction between the patient and the GP or between the GP and TD from various physical locations. This latter real-time synchronous teledermatology format is time-dependent and labor-intensive. Finally, hybrid teledermatology is a combination of store-and-forward and real-time consultation. High-resolution digital images are assessed and at the same time, direct video interaction takes place between the patient and the GP or between the GP and TD.
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