80 CHAPTER 4 cases. In addition, only two out of eight melanoma were correctly pre-diagnosed in the GP referral letters. In our study, GPs detected 14 percent of all melanoma diagnosed by teledermoscopy. The positive predictive value of GPs in melanoma detection for both studies was equal, 0.67. One of the limitations of this study is that in Dutch GP practice diagnoses are registered according to the International Classification of Primary Care (ICPC) and recorded according to SOAP notes (Subjective, Objective, Assessment, Plan). The ICD-10 classification of diseases was thus a new classification method where GPs were unfamiliar with, when it was implemented in 2015. GPs becoming more familiar with ICD-10 coding might therefore have contributed to the increase in the number of (correct) ICD-10 pre-diagnoses registered by the GPs in our study. Hence, in this study we only included GPs who started with teledermoscopy after the ICD-10 was implemented in the Ksyos system, to research how their pre-diagnosing patterns changed according to the ICD-10 coding in three years’ time. Also, GPs might use teledermoscopy in general practice to fasten the face-to-face consultation with the patient and not solely for support in diagnosing. If a GP correctly prediagnosed the patient, but did not fill in this diagnosis in the system, this would affect the GP’s PPV in diagnosing skin disorders. During the time of our study it was not mandatory for the GP to fill in the ICD-10 code in the system and this would thus not be seen in our data. Though this study has several limitations, the strength of the study is that we had a large database available of teledermoscopy users and were able to include only GPs who started with teledermoscopy when the ICD-10 coding system was first implemented in the Ksyos system and had continued and frequent use of the system in the past three years. We could therefore accurately address their progress in expertise in pre-diagnosing skin disorders based on ICD-10 coding. CONCLUSIONS Teledermoscopy supports GPs in assessing suspicious lesions of patients and their need for referral to a dermatologist. Continual use of teledermoscopy over the years appears to slightly enhance GP sensitivity in diagnosing skin disorders based on ICD-10 coding. However, GPs PPV for the main ICD-10 codes showed a decrease over the years. Though GPs become more perceptive in recognizing benign neoplasms (D10-D36) and melanoma (C43-C44), teledermoscopy detected a high number of melanoma not correctly prediagnosed or otherwise not detected by GPs in this cohort. Hence, teledermoscopy has the potential to enhance GPs’ expertise in skin disorder diagnosing, but remains essential in early melanoma detection even after GPs’ continued and frequent teledermoscopy use.
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