52 CHAPTER 3 METHODS Teledermoscopy in Dutch primary care In the Netherlands, GPs function as a gatekeeper by which patients must visit their GP before they can be referred to secondary care. GPs who require advice from a remote dermatologist can send a teledermoscopy consultation based on their own selection of patients with a suspicious skin lesion. Ksyos [22] is one of the largest store-and-forward teledermoscopy providers in the Netherlands. In the Ksyos teledermoscopy consultation system, the GP adds a maximum of four (dermoscopic and overview) pictures and provides additional patient data (e.g., findings of a physical examination, anamneses, medication, (differential) diagnosis). The GP can add additional questions to the teledermatologist in a free text field. Patients provided oral consent to the GP to send a teledermoscopy consultation to a teledermatologist. The teledermatologist has to answer the consultation within two working days by providing the diagnosis which is automatically mapped on the International Statistical Classification of Diseases and Related Health Problems, 10th revision (ICD-10) classification [23] (providing a diagnosis is mandatory since July 2015) and advise on an in-person referral, medication, treatment and management of the patient in free text. The teledermatologist could also respond that a diagnosis could not be provided. Ksyos does not have access to an eventual histopathology diagnosis to compare with the diagnosis provided by the teledermatologist. Upon sending and closing the teledermoscopy consultation, embedded non-mandatory evaluation questions Q1 and Q3-Q5 are posed to the GP by a pop-up in the Ksyos teledermoscopy consultation system (Figure 3.1; Q1-Q5). The mandatory evaluation question Q2 is embedded in the teledermoscopy form for the teledermatologist. Answer options for Q1 and Q3 include “Yes” or “No”, for Q2 “Yes”, “No” or “Not applicable” (NA), for Q4 and Q5 “Yes”, “No”, “Some”. The “NA” answer option (Q2) was intended for teledermatologists who did not want to explicitly respond with “Yes” or “No” on Q2. These evaluation questions and answer options were designed by Ksyos and implemented since the start of the teledermoscopy service and could not be adapted for research purposes only.
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