187 GENERAL DISCUSSION The costs could, for example, be offset by health insurers by the costs that are no longer incurred for unnecessary dermatology physical referrals. Purchasing the appropriate photography equipment will probably save health insurers money, since no longer invoicing for unnecessary physical referrals to a dermatologist through the use of digital dermatology leads to savings in healthcare costs. Improve the human-computer interface and solve technological issues This thesis also demonstrated that human computer interface and technological issues on the telemedicine platform might have negatively affected GPs’ motivation to use digital dermatology and improvements on these aspects can raise the use of digital dermatology to a higher level. Chapters 4 and 5 showed that (differential) TD diagnoses were absent or considered as non-assessable in more than 10 percent of the consultations. These studies did not examine the TD’s experience in teledermoscopy assessment and their reasons for non-assessment. These missing diagnoses may be the result of insufficient patient information provided by GPs or (dermoscopic) photographs of insufficient quality [17,18,26]. Therefore, we suggest implementing an understandable and straightforward image quality checklist or guideline on the platform to educate GPs how to take (dermoscopic) photographs with sufficient quality [27]. In this way, GPs are guided step-by-step to submit only photographs with sufficient quality and the correct number and type (overview, detailed, dermoscopic) or are otherwise warned to retake the images. Furthermore, we recommend that a quality validation step, for example by means of artificial intelligence, is implemented in the digital dermatology platform verifying whether the photographs’ quality is indeed sufficient and if the correct number and type of images are taken and uploaded by the GP. Furthermore, GPs have access to many digital health applications for different purposes and have to actively search for the digital dermatology platform. Most GPs can log into the digital dermatology platform directly from their GP Information System (Dutch: Huisarts Informatie Systeem (HIS)) by clicking on a separate button. However, when GPs use their standard referral flow to secondary care and create a new digital referral request in their HIS, the system solely suggests physical referrals to healthcare institutions and does not show the teledermatology and teledermoscopy services. Therefore, to increase the frequency of use, we recommend that the digital dermatology platform is intuitive and digital dermatology referrals are as easy to start from a GP’s HIS as the other digital referral platforms (e.g., ZorgDomein) to secondary care. In addition, user-friendliness of the interfaces of digital dermatology applications is required to increase their use among GPs. First, the input fields in the teledermatology and teledermoscopy requests need to be revised. Only a few of the requests from GPs and dermatologists were implemented in the user interface of the teledermatology and teledermoscopy services over the past few years. In addition, mandatory input fields are general and not adaptive or interactive to particular skin questions. For example, for nevi, 8
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