We performed a mixed-methods evaluation using broad categories of the Canada Health Infoway (CHI) Benefits Evaluation Framework [9] to include at least one aspect of qualitative and quantitative analyses for each category as well as case studies, surveys, and semistructured interviews. The key results were triangulated in a final, overarching analysis. This study was approved by the research ethics boards of Women’s College Hospital and the University of Toronto in Toronto, Ontario, Canada.

Parameters were chosen to balance convenience (encourage use) and pragmatic considerations of the practice guidelines for teledermatology [8]. We selected a store-and-forward design with secondary teledermatology, as it is a funded model in our region, and secure institutional email as a common, accessible technology. Clinically, the referring providers were informed that they could send any request they deemed appropriate and a response would be guaranteed within 1 week. The primary author was the sole consultant providing responses. The details of the implementation are described in Table 1.

A total of 76 participants used the service between November 2016 and December 2017, including 17 (22%) pediatric patients, 3 pregnant patients, 28 men (37%), and 48 women (63%). Consultation data for all patients were subjected to chart review. The average age of patients using the service was 39.3 years, and the average response time was 23.5 h, with a minimum response time of 0.5 h and a maximum time of 142.6 h (6 days).

Clinical characteristics were grouped into diagnostic dermatology categories, similar to previous teledermatology evaluations [12], and are presented in Table 2. Each case was broadly categorized into an easily recognizable presenting complaint: a “rash,” which presents in multiple areas of the skin with the same general appearance, most typically represented by eczematous dermatoses, infections, or reactive skin conditions; a “lesion,” which is a focal, persistent eruption on the skin, typified by benign and malignant growths; or a “question” about a treatment (Table 3). Of all cases, 12 (16%) required a subsequent in-person visit.

We assumed that clinicians would use photographs from a patient visit to their office; however, in 14% of all consultations, parent- or patient-initiated photographs were used. In 6 (35%) of the pediatric cases, photographs for analysis were provided by the parents, and 5 adult patients provided their own photographs to the clinician. None of these patients required additional photographs or in-person follow-up, and cases wherein the data were available, the conditions were appropriately resolved. In one case, the parent-initiated photograph showed evidence of a rare condition that occurs only under specific conditions.

Our results showed that it was possible to manage 94% of “rashes” by teledermatology alone, but only 59% of “lesions” could be managed by this method. Additionally, in 21 cases (27%), the primary management aimed to increase the prescribed potency of or choose a more-effective vehicle for the topical steroid used. Finally, in at least one case, a response time of 24 h permitted initiation of therapy to prevent postherpetic neuralgia complications of herpes zoster; however, the recommended 72-h time window for treatment [13] would have been exceeded if the maximum response time of the service (1 week) was applied in this case.

Of the 14 invitations sent, we received 11 responses for the online survey (79% response rate). Responses were averaged and interpreted according to the final score. The results of the survey and the Likert interpretation of the average score are presented in Table 4. Feedback was generally very positive for satisfaction and educational value. The clinicians reported that the service did not save any time, but increased the administrative time. However, they indicated that the benefits of the service outweighed the lost time and the service had educational value. No adverse events were reported.

A total of 76 patients were sent paper surveys and 26 patients, who had provided an email address for provider registration at the institution, were sent a duplicate email invitation.

We received 22 responses (29%). Patients were generally satisfied with the service and reported that it saved time and money and prevented them from missing work. However, their views were divided when they were asked if they “prefer to use this system instead of going to see a specialist in-person.” Their responses were instructive: Some patients indicated that they generally prefer in-person consultations, as they provide a greater opportunity to ask questions and clarify the rationale for therapeutic choices. These results are summarized in Table 5.

A total of 8 interviews of 4 referring providers who had experience with the system and 4 consultant dermatologists who had experience with other implementations of teledermatology or were open to participating in the service were analyzed.

Efficiency of care emerged as a theme. For referring providers…

Although dermatologists were open to email communication, they expressed concern that additional administrative overhead may prevent uptake; for example, one dermatologist felt that,

Interviews supported the data from patient surveys that both providers and patients were satisfied with the service. One provider stated,

In addition, providers expressed satisfaction for the educational value of the system with regard to the speed of access; for example, one provider commented,

Finally, referring providers noted that the service was very useful in situations when they identified the diagnosis but wanted to be up to date on management. One provider stated,

Dermatologists agreed that they were more comfortable answering management questions than diagnostic questions in telemedicine or remote situations; one dermatologist said,

The concurrent triangulation analysis was consistent with our hypothesis: The intrainstitutional teledermatology service was effective and satisfying to providers and patients even when geographic access was not a barrier. Store-and-forward teledermatology demonstrated diagnostic concordance [17]. In addition, a previous systematic review supported the idea that teledermatology is associated with high satisfaction [18]. Prior work has suggested that cost-effectiveness is not a universal feature of teledermatology [19] and would be highly dependent on regional factors. In our study, the service demonstrated 30% savings in visitation fees [16], and according to the patients, the service saved time and money and prevented them from missing work, which are important components of social cost.

To our knowledge, this is one of the first few studies to investigate the educational potential of teledermatology for referring providers embedded in a consultation service. Other studies have reported the value of incorporating trainees into the teleconsultation process [20] or initiatives such as project ECHO [21] that explore virtual education separate from the service. In our initiative, we found that an appropriately structured consultation note that explains clinical reasoning and offers a treatment ladder was educational and helpful to the referring provider. Furthermore, both dermatologists and referring providers suggested that the greatest educational value of this service was management, not diagnosis. This is supported by the chart review, which showed that 27% of all recommendations involved only alteration of the existing topical treatment. A dermatologist noted, “We all know that the challenge with skin diseases; people don’t think about it from a morphology point of view. They think about it as; that person I saw with psoriasis three years ago, this looks like that, right? And so that educated piece, in terms of diagnostics, I think would be lost.” (Interview D4). Incorporating formal management and educational initiatives into teleconsultation is an area of potential expansion and study in the future.

In our chart review, 41% of lesions required a subsequent in-person visit compared to only 6% of rashes. Therefore, in the future, such a service would be most productive and efficient if it targeted the management of “rashes” alone. This finding is in line with the view of dermatologists who expressed concern about their comfort with regard to managing lesions by traditional teledermatology and the abovementioned educational findings: There are fewer management options for lesions and therefore potentially less educational value in the discussion of those consultations.

Future services should consider a 24-h consultation response time to manage the most-serious outpatient clinical scenarios. Other pilot services in the literature meet or surpass this response time [22,23]. Important clinical conditions that are time sensitive, meaning that they need ≤24 h for diagnosis and rapid management in dermatology, are infections requiring intervention and serious drug rashes [24] because of the risk of significant morbidity and mortality. In our study, there was only one case of a treatable infection where identification within the period prevented morbidity; however, this may be because referring providers would less likely consider using teledermatology for high-acuity dermatoses if the “maximum” response time allotted was 1 week. However, setting the response time too low may decrease the number of potential dermatologists willing to participate in the service, unless adequately remunerated or alternatively structured (eg, shared “on-call” responsibilities or triage responsibilities delegated to trainees or other health care professionals).

One limitation of this study is that this was a small case study at a single institution in a region that is supportive of virtual care. Therefore, the results may not be generalizable. As the primary author is currently the only consulting teledermatologist in our institution, there may be a better way to provide improved care and faster response times than a “usual case” scenario, which could lead to potential bias towards positivity. In addition, follow-ups or “second opinion” consultations may not have been accounted for if they were referred to other care clinics in the city outside the circle of care of the institution.

This is the first reported study on intrainstitutional teledermatology using a mixed-methods approach to explore the benefits of teledermatology, namely, rapid access, high satisfaction, safe and effective clinical outcomes, and increased efficiency and productivity in the health care system. The integration of teledermatology into a routine clinical workflow has remarkable potential value, irrespective of existing access to consultative dermatology. Specifically, by reducing healthcare visits, patients can save time and money and avoid missing work. Additionally, this study provides evidence that management of rashes is ideal via teledermatology, which may lead to better outcomes because of the rapid response and high proportion of cases that can be managed through teledermatology alone. This finding is concordant with the expressed opinions of dermatologists in our study who did not want to assess lesions with traditional teledermatology. The impact and satisfaction of an intrainstitutional teledermatology service that primarily targets rashes and, according to our study, ideally provides responses within 24 h to maximize safety, is worth evaluating in future studies. Further research is necessary to elucidate the educational value of intrainstitutional teledermatology for referring providers and its potential for saving costs.