86 CHAPTER 5 Previous teledermoscopy studies in other settings investigated common TD-provided telediagnoses and the percentage of patients for whom, due to teledermoscopy, a physical referral to a dermatologist could be avoided [5-11]. However, these studies did not focus on patients who would initially not have been referred by the GP without the availability of teledermoscopy. Nor did they aim to assess whether the GP’s initial decision to refer or not refer a patient before the teledermoscopy consultation changed after the TD assessment for skin lesions diagnosed by the TD as malignant, premalignant, or benign. Therefore, for these diagnosis groups, the impact of the availability of teledermoscopy on the GPs’ referral decisions to dermatology care is still unknown. Therefore, this study assessed and compared GPs’ self-reported initial referral decisions before teledermoscopy with their final referral decisions after teledermoscopy for (pre)malignant and benign TD-diagnosed skin lesions. METHODS Setting and teledermoscopy process description In the Ksyos-secured teledermoscopy digital health record system, a GP starts the teledermoscopy process with a standardized consultation request and uploads the obtained (detailed, overview, dermoscopic) images of a patient’s skin lesion. After a GP has filled in patient information, such as year of birth, sex, prehistory of skin cancer, structured anamnesis, optional provisional diagnosis, and additional notes, the GP sends the teledermoscopy request to a TD for review. The TD then provides a primary diagnosis (a mandatory and an optional differential diagnosis) in a text entry field and referral recommendations, which may include advice for the GP on the patient management plan. Further, a GP is asked to answer 2 similar nonmandatory self-administered questions: (1) “Would you have referred this patient if teledermoscopy was not available?” and (2) “Are you still referring this patient to the dermatologist?”. These questions, which are embedded in the Ksyos system by default, retrieve information about (1) the GP’s initial decision to refer a patient to a dermatologist (Yes, No) when sending the teledermoscopy consultation request to a TD and (2) the GP’s final referral decision (Yes, No) at the time of closing the teledermoscopy consultation after the TD assessment. As of July 2015, the Ksyos system generates an ICD-10 (International Classification of Diseases, 10th revision) [14] code by which diagnoses provided by TDs in teledermoscopy consultations are automatically classified. Instead of describing the primary diagnosis in a free text entry field, TDs can also choose 1 of 3 icon buttons; no diagnosis (ICD-10 code: R69), no abnormalities (ICD-10 code: R68.8), or nonassessable (−).
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