Our study was deemed exempt from ethics approval by the University of Washington Human Subjects Division and the University of Washington Institutional Review Board (IRB ID: STUDY00010266).

We conducted a cross-sectional study of dermatologists’ perceptions of teledermatology implementation during the COVID-19 pandemic. We surveyed members of the Association of Professors of Dermatology (APD) between November 20 and December 9, 2020 (Multimedia Appendix 1). An initial email was sent on November 20, and it was resent on December 2 to try to increase the response rate. The survey focused on (1) the acceptability, feasibility, and appropriateness of teledermatology and (2) organizational readiness for implementing teledermatology. We used an abbreviated, single-item version of a validated scale [9] to assess the acceptability of different teledermatology modalities (eg, synchronous audio and video and stored digital photos). Using the same scale, we assessed the acceptability of teledermatology for different dermatologic conditions and purposes (eg, lesions of concern and medication monitoring). We also incorporated selected subscales from the validated Organizational Readiness to Change Assessment (ORCA) instrument (eg, culture and resources). There were 26 ORCA questions, which were scored on a 5-point Likert scale ranging from “Strongly Disagree” to “Strongly Agree.” The possible ORCA scores ranged from 26 to 130, with higher scores indicating higher organizational readiness for change. The entire survey was tested for face validity and readability through pilots with dermatologists. It was iteratively refined based on their feedback. The survey was administered via email, and responses were collected anonymously. ORCA scores were reported as unweighed composite scores, and participants were stratified by ORCA score tertiles—“low,” “medium,” and “high” organizational readiness for change (Table 1). We did not perform statistical hypothesis testing, in accordance with best practices [10].

In our study, although most dermatologists (33/35, 94%) planned to continue using teledermatology after the pandemic, there was some indication that they lacked support in certain areas (eg, staffing and facilities) during implementation early in the COVID-19 pandemic. Additionally, not all teledermatology modalities were equally acceptable or feasible. Among respondents, telephone and synchronous audio and video visits were the least acceptable and feasible modalities, whereas modalities that combined stored digital photos with telephone visits or synchronous audio and video visits were the most acceptable and feasible modalities.

Teledermatology has been a part of dermatologic care for over 25 years [11]. Although consultations involving stored digital photos (store and forward) have historically been the dominant teledermatology modality in clinical practice [12], the COVID-19 pandemic has resulted in the rapid implementation of synchronous audio and video teledermatology [13].

Although the majority of dermatologists (33/35, 94%) in this study planned to continue using teledermatology after the pandemic, there is likely some variability in intentions to continue using teledermatology, depending on the population surveyed and timing. An earlier survey by the American Academy of Dermatology in May 2020, which included a larger proportion of private practice dermatologists, found that just over half (58%) of dermatologists planned to continue using teledermatology after the pandemic [13]. Despite the differences, both surveys highlight the importance of teledermatology in the future, with over 50% of dermatologists intending to practice teledermatology.

Overall, respondents supported the use of teledermatology after the pandemic; however, we found that both telephone visits and synchronous audio and video visits without stored digital photos were the two least acceptable and feasible modalities. This finding aligns with patients’ experiences with teledermatology. Despite high levels of patient satisfaction and willingness to continue using teledermatology after the pandemic [4,5], satisfaction with dermatology telephone visits is lower, and fewer dermatology patients are willing to use telephone visits for future dermatologic care [14]. Taken as a whole, our findings build on a growing body of evidence that certain modalities, particularly telephone visits, are less acceptable to both patients and care providers. Dermatologists rely upon the clear and accurate visualization of the skin, which telephone and synchronous video/audio visits alone may not offer.

Incorporating stored digital photos may overcome some of the limitations of using synchronous audio and video visits and telephone visits in isolation. Acceptability was higher for including stored digital photos with synchronous audio and video visits or telephone visits when compared to that for visits without stored digital photos and consultations involving stored digital photos alone. Prior studies that were conducted during the COVID-19 pandemic showed that care providers were split between preferring synchronous (54%) and asynchronous (46%) modalities but did not assess the combination of asynchronous and synchronous approaches [15]. Dermatologists may be able to maximize the benefits of synchronous modalities (synchronous audio and video visits and telephone visits) and asynchronous modalities (stored digital photos) by combining them to create a more acceptable and preferable teledermatology experience.

We also found that there may be variability in the acceptability of teledermatology based on the type of dermatologic condition and visit. The majority of surveyed dermatologists felt that synchronous video/audio (without stored digital photos) was acceptable for “existing patients” (29/32, 91%) and “medication monitoring” (29/32, 91%). Fewer respondents felt that synchronous video/audio (without stored digital photos) was acceptable for “new patients” (12/32, 38%), and very few felt that teledermatology was acceptable for “lesions of concern” (5/32, 16%) and “total body skin exams” (2/32, 6%). The American Academy of Dermatology’s survey found a similarly low number of dermatologists who were comfortable with performing total body skin exams via teledermatology, with 96% believing that this requires an in-person examination [13]. This work adds to our understanding of the types of patient concerns for which teledermatology is the most acceptable. We hope that teledermatology guidelines for best practices can evolve via this growing collection of work.

When implementing novel health care technologies (including teledermatology technologies), organizational factors, such as organizational readiness for change, are important determinants of implementation success [16]. We found that although support for teledermatology implementation was high in most areas (eg, training and care provider buy-in), dermatologists lacked organizational support in other areas, such as staffing support and facilities. In addition, we found that respondents with a “low” organizational readiness for change tended to find synchronous audio and video visits less acceptable when compared to respondents with “medium” and “high” ORCA scores. It is plausible that in dermatology practices with a lower organizational readiness for change, limited support for newly implementing synchronous audio and video teledermatology [13] resulted in negative experiences during the COVID-19 pandemic. This hints at the potential importance of organizational readiness in determining the success of teledermatology implementation. Although specific implementation process details were outside the scope of this work, lower scores for important implementation strategies, including having a clinical champion, giving feedback to clinicians, and providing education, contributed to respondents having “low” scores for organizational readiness for change, and this may provide clues as to the specific implementation strategies that are important for the successful implementation of synchronous audio and video teledermatology early in the COVID-19 pandemic. Future research will be needed to explore the roles of specific implementation strategies, implementation processes, and costs in determining the success of newly implemented teledermatology programs.

We acknowledge that this cross-sectional survey has significant limitations, given its modest sample size and response rate. Therefore, we cannot draw definitive conclusions on the associations between organizational readiness for change and teledermatology implementation outcomes. Still, our total of 35 respondents and response rate of 7% (35/518) are similar to those of other nonincentivized physician surveys [13]. For these reasons, the findings of this survey may not be generalizable. As the survey was distributed to the APD, the majority of respondents (32/35) practiced in academic dermatology settings. Thus, respondents with an interest in teledermatology may have been overrepresented. Additionally, respondents were mostly White (24/35, 69%); as such, the opinions of dermatologists from all backgrounds were not captured. Despite these limitations, this work provides valuable descriptive insights into the role of implementation science in understanding teledermatology implementation during the COVID-19 pandemic.

This study serves as an introduction to how implementation science research methods can be used to understand the implementation of novel technologies in dermatology. Our work builds on prior work by further characterizing the acceptability and feasibility of different teledermatology modalities. Our study also contributes initial insights on how dermatology practices and health care systems can support dermatologists in successfully incorporating teledermatology after the pandemic. Finally, this work highlights newer methods for identifying organizational factors that can be optimized to improve future teledermatology implementation efforts.