38 CHAPTER 2 care providers should be authorized and verified by a unique authentication number. Confidential patient data should be protected, encrypted, and encoded by transmission. Additionally, the data flow should be logged and it should be documented which health care provider received which information and when. International Organization for Standardization (ISO) standards, like the ISO/TS 13131:2014 [34] on Telehealth services or the ISO/ IEC 27001:2013 [35] on information technology security, can be very useful tools to address these issues. Fourth, although images delivered through teledermatology provide a lot of information, additional (patient) information and medical history is needed for deciding on final diagnoses or treatments. Firstly, data on some patient demographics (e.g., identification number, name, gender, age, etc.) is required. Furthermore, the patient history (e.g., complaints and symptoms, allergies, medication use etc.) and a description of the skin lesion (e.g., color, shape, borders, size, location, surface, number of lesions, distribution, and etcetera) could provide necessary clues [11,22]. A technological barrier concerns the interfacing of the teledermatology application with the existing electronic medical record [32]. Furthermore, user satisfaction often is a barrier in the acceptance of technology and a key factor in the implementation of teledermatology. Orruño et al. [36] developed the teledermatology technology acceptance model (based on the technology acceptance model (TAM) of Davis [37]) and determined which factors affect the intention of physicians to use teledermatology. The teledermatology TAM describes the intention of physicians to use teledermatology and the acceptance of teledermatology in three different contexts: the individual (compatibility of technology, attitude), the technological (perceived usefulness of technology, perceived ease of use of technology and habits), and the organizational (facilitators, subjective norm) factors. Habits, compatibility, facilitators, and subjective norm are additional dimensions to the original TAM. Habits encompass behavior which is now, with the use of teledermatology, automatized [36], e.g., do the individuals feel comfortable with the information and communication technology? The developers of the new teledermatology model found that facilitators (organizational infrastructure, training, and support) significantly influence the intention to use teledermatology [36]. Training should include how teledermatology provides access to timely dermatologic care, how physicians should take high-quality images and how to send images securely [38]. Especially the organizational context of the teledermatology implementation is very important [36], do individuals believe that this organizational infrastructure provides support to use the system? So, implementation requirements for user acceptance of teledermatology are (1) full and continuous technical support to users, (2) training of physicians (3) and an appropriate organizational infrastructure. The last important factor which should be considered is the standardization of imaging and equipment of teledermatology services. There are no universal imaging standards
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