192 CHAPTER 8 lacks validated insight questions on the specific use of digital dermatology care in general practice. Therefore, new instruments need to be developed and validated that include digital dermatology specific questions and questions that take the patients perspectives on specifically dermatology home consultation into account. Afterwards, these types of questionnaire studies could support telemedicine organizations in continuously identifying barriers that hinder the use of their digital dermatology services, create solutions to improve the service quality when necessary, and to adjust the services to the needs of GPs, patients, and dermatologists. Such improvements would keep the services successful in GP care and at patients’ homes and could stimulate future use. Besides for telemedicine organizations, patients, GPs, and dermatologists, these questionnaire studies might be of value to patient advocacy organizations, health insurance companies, public health inspections and government policymakers, in order to monitor and measure the quality of (digital) care from their perspectives and to make decisions about the reimbursement of incurred costs. The digitalization of Dutch healthcare has previously been left to the market resulting in fragmented and mostly temporary initiatives without any involvement from the government. The COVID-19 pandemic boosted the use of digital health applications and as a consequence of this swiftness, GPs were flooded by innovative initiatives with various applications currently circulating in primary care. We recommend that especially in countries with various telemedicine organizations or different digital dermatology applications, quality benchmarks should be introduced to assure the quality of digital dermatology services and the performance of telemedicine organizations. Healthcare organizations, health insurance companies and the government should collaborate in defining these benchmarks and only invest money and energy in well-functioning and high-quality digital dermatology initiatives with structural funding [10]. In addition to the development of these benchmarks for digital dermatology services, future studies should investigate whether periodic certificates should be issued to GPs or dermatologists to reward them for regularly performing digital care, to demonstrate whether they meet the digital dermatology requirements (education in taking photographs, equipment, etc.) and to guarantee the quality of the provided feedback by TDs. For example, in aviation, pilots have to complete flying hours and their competencies are regularly rechecked, whereas such periodic checks do not exist for stakeholders using technology in healthcare. Although there is a more general system for postgraduate accreditation for GPs, specific accreditation for telemedicine is non-existent. Such quality benchmarks, certifications, structural audits and feedback on GPs’ and dermatologists’ performances might improve the adequate use of digital dermatology services. Medical record and database linkage The main limitations in this thesis were lack of available data from other teledermatology providers in The Netherlands and missing data regarding the clinical follow-up and confirmed diagnoses after the digital dermatology consultations. Insights into clinical
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