188 CHAPTER 8 GPs are not obliged to fill in the items “complaints” and “evolution of the skin lesion” in the consultation request. Consequently, these fields were not always completed by the GPs, while this information is highly relevant for assessment of the skin lesion by the TD. Furthermore, the results in Chapter 3 suggest that the advice of TDs for patient referral is not always conceivable in yes or no and that in some cases TDs preferred to write out their advice to the GPs in free text. Due to privacy limitations, we were not allowed to analyze the free text fields filled in by the TDs or GPs in the consultation forms. One of our recommendations is to review the digital dermatology process, input fields and evaluation questions used in the digital dermatology platform together with GPs and TDs and to optimize the user interface of the dermatology application to the information required for decision-making. These reviews could provide input to making the digital dermatology interface adaptive and interactive so that GPs are guided through the task of filling in the required information for each skin complaint and to align the service with GPs’ work processes. STRENGTHS AND LIMITATIONS This section will discuss the main strengths and limitations of the studies in this thesis. This thesis included a review of the literature, retrospective studies on the added merits of store-and-forward teledermoscopy consultations for GPs in Dutch primary care, and the development, validation, adaption and use of a questionnaire to monitor and assess GPs’ experiences with digital dermatology services. Strengths The first strength of the studies in this thesis is that all teledermatology, teledermoscopy and digital dermatology home consultations were performed in Dutch daily GP practices. Most studies in the literature simulate digital dermatology services in a study setting where the services are offered only to a selected group of patients in a controlled setting or participants are chosen in secondary rather than primary care settings [17,18,28,29]. The fact that these services had already been integrated into Dutch daily GP practices provided a unique opportunity to study defined quality and performance outcomes (Chapter 3), to evaluate for different diagnosis groups whether the GPs changed their initial self-reported referral decisions after the teledermoscopy consultation (Chapter 5), and to assess GPs’ experienced facilitators and barriers with the services during the COVID-19 pandemic from a sociotechnical perspective (Chapter 7). The second strength of the retrospective studies in this thesis is that a large teledermoscopy database with teledermoscopy data over three, five and eleven years was available (Chapter 3, 4, 5). This large dataset allowed us to study GPs’ referral decisions before and after TD assessment for benign, premalignant, and malignant lesions and to determine GPs’ gained expertise in diagnosing skin disorders after continued use. The eleven years of teledermoscopy evaluation in Chapter 3 is, by including over 18,000
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