40 CHAPTER 2 DISCUSSION This narrative literature review of PubMed based on publications selected by one reviewer focused on the actors, purposes, subspecialties, delivery modalities and technologies, business models integration of teledermatology services into national healthcare systems, preconditions and requirements for implementation and added value of teledermatology. Teledermatology is used by healthcare professionals for consultation of other colleagues, triage, and follow-up of patients and education of more junior healthcare professionals. It enables direct digital communication between the patient and primary health care provider or dermatologist, between general practitioners and dermatologists or among dermatologists. Teledermatology can be delivered by three different modalities: store-andforward, real-time interactive, and hybrid. As pointed out in the literature, teledermatology has some advantages and could be beneficial for patient care. Teledermatology reduces patient travel time, avoids unnecessary referrals, lowers costs, and improves efficiency of care. More importantly, teledermatology has proven to be at least equally effective as physical patient care and does not negatively influence the quality of care delivered to the patient. Despite the benefits of teledermatology, experiences of patients should be taken into account while implementing a teledermatology program. Because of methodological deficiencies in the evidence currently available, satisfactory explanations of the underlying reasons for patient satisfaction or dissatisfaction with telemedicine are not available [48]. Besides, reliable and validated instruments to measure satisfaction and quality aspects of teledermatology from a patients’ perspective have not been developed yet [7]. In the Netherlands, the consumer quality index (CQ-index) [49], a standardized method for developing surveys and measuring healthcare quality from the patients’ perspective, was introduced in 2006 in order to promote patient-centered care. To measure the quality of care delivered through telemedicine from a patients’ perspective, we are developing a valid and reliable questionnaire, based on the framework of the CQ-index. The responses to such a validated CQ-index for teleconsultation could be used to enhance the quality of care delivered by telemedicine, give choice information to healthcare consumers, advocacy information for patients and patient organizations to inform their members about the quality of care of telemedicine services. Additionally, the results could be used by different stakeholders: by patients to decide about their healthcare provider; by the public health inspection to measure the quality of care; by the health insurance companies to decide about reimbursement; and by the government to monitor quality of healthcare. Furthermore, as indicated by Whited [50] there is a “research gap” on the effect of teledermatology on patients’ quality of life. Quality of life is an important outcome measure for skin diseases and teledermatology may have a positive effect on quality of life of patients. Patients do, for example, not have to visit the dermatologists physically but can visit their GP nearby. Especially for chronic patients, patient-assisted follow-up
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