182 CHAPTER 8 In Chapter 4 we investigated the added value of teledermoscopy as expertise gain of GPs diagnosing skin disorders, based on the diagnoses provided by GPs and TDs. This preliminary study indicated that GPs somewhat improved their expertise in diagnosing skin disorders after continued use of teledermoscopy, indicating that the service is of limited added value for GPs as a learning tool. In addition, GP diagnosis sensitivity for skin disorders and the number of GP pre-diagnoses confirmed by the TD slightly increased over time while the total positive predictive value of diagnoses given by the GP slightly decreased over time. Furthermore, we found that 50 teledermoscopy consultations were diagnosed by the TD as melanoma and 43 of these 50 consultations were not prediagnosed by the GP as melanoma. Therefore, teledermoscopy, more specifically TD’s advice, remains a valuable tool for early detection of melanoma even after frequent and continuous use of teledermoscopy by GPs. Regarding (pre)malignant and benign TD-diagnosed skin lesions, we examined in Chapter 5 the GPs’ self-reported initial referral decisions before teledermoscopy with their final referral decisions after teledermoscopy. This chapter showed that the availability of teledermoscopy assists GPs in their decision-making of whether they should refer patients to a dermatologist. In half of the studied teledermoscopy consultations, the GPs adjusted their initial self-reported referral decision of patients that they made before teledermoscopy versus their final referral decisions after the TD assessment. Furthermore, GPs would initially not have directly referred 57% of the patients with a malignant TD diagnosis and 16% of the patients with a premalignant TD diagnosis for a face-to-face dermatology consultation but reversed their decision and referred these patients to a dermatologist after the teledermoscopy consultation. In addition, teledermoscopy avoided 75% physical referrals of patients with benign, low-complex skin lesions that GPs would have referred to a dermatologist without the teledermoscopy service. Part III: GPs’ perspectives about store-and-forward digital dermatology care In Chapter 6 we developed and validated a Store-and-Forward Telemedicine Service User-satisfaction Questionnaire (SAF-TSUQ) to monitor and assess health care providers’ experiences with contracted store-and-forward telemedicine organizations (their services and used platform). Questionnaire development included four steps. First, an exploratory literature search was performed on current validated telemedicine satisfaction questionnaires. Second, a focus group with a telemedicine domain and a humanfactors engineering expert was held to appreciate the questionnaire items obtained from the literature. Third, a structured focus group with stakeholders (customer service employee and telemedicine account managers) was performed to evaluate the relevance and formulation (wording) of the questionnaire items. Fourth, two questionnaire pretesting rounds were conducted. During these pre-testing rounds, 18 medical specialists, paramedics and GPs reviewed the questionnaire and evaluated the comprehensiveness and applicability of the questionnaire items. After development, the 61-item questionnaire
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