Dermatologists have been identified as “behind the curve” in digital innovation [1]. Prior to the pandemic, teledermatology had not been used as a consultation method in outpatient clinics within Scotland. Although lesion photo triage was available in a limited number of health boards, its primary purpose was for enhanced referral triage, and it required patients to have face-to-face contact with a clinical photographer. Pandemic restrictions necessitated a reduction in face-to-face consultations, with priority given to essential cancer and emergency services. To provide continuing patient care, existing outpatient models were redesigned to enable the use of store-and-forward asynchronous teledermatology. In comparison with synchronous real-time teledermatology (primarily video consultations), asynchronous teledermatology involves electronically transmitting clinical details and images to a clinician for review at a different time and location [2]. This method was preferred, as it has been widely reviewed, has the potential to improve clinical efficiency [3-5], provides flexibility and convenience to both clinicians and patients, and confers environmental benefits through reduced travel and carbon emissions [6]. Asynchronous teledermatology also permits the uploading of higher-quality images of specific lesions by patients. This is preferable to relying on lower-resolution videos and avoids the potential pitfalls of slow internet connection speeds, which are issues in the case of synchronous teledermatology [7].

A government-sponsored initiative sought to fund innovative solutions for use in modern health care settings. Dermatology, with its high volumes of outpatient consultations, was identified as an area with development potential, and software companies were asked to pitch their ideas for novel digital systems to improve health care efficiency. Through this, an asynchronous teledermatology platform was developed collaboratively by dermatology teams from 2 Scottish health boards (National Health Service [NHS] Forth Valley and NHS Greater Glasgow and Clyde) and a digital agency [8]. NHS Forth Valley serves a diverse geographical area in the heart of Scotland, and NHS Greater Glasgow and Clyde is the largest NHS organization in Scotland and one of the largest in the United Kingdom. Clinicians’ and patients’ views were taken into account when designing the system to make it user-friendly at both ends of the interface.

The platform allows patients to submit information and photographs of their skin condition, which are then assessed by a clinician. Afterward, the patients receive a response, and a summary of the consultation is sent to primary care and stored on the patients’ electronic records.

Although the platform was originally designed for follow-up consultations, the challenges posed by the COVID-19 pandemic lockdown prompted its more widespread use, including for new consultations. We therefore evaluated its feasibility as a consultation platform, with respect to efficiency, patient satisfaction, and its use as a diagnostic or triage tool.

During the 11 weeks of the first national lockdown, 405 digital assessments were completed for 394 patients (Table 1). Of the 405 assessments, 297 (73.3%) were for new referrals, while 108 (26.7%) were return consultations. Patient ages ranged from 1 to 98 (mean 48) years, with 30.7% (121/394) aged older than 60 years, and parents of 12 children successfully completed digital assessments. Two-thirds of patients used a smart device, with the remainder using a PC or laptop (263/394). Further, 80% (324/405) of submitted images were considered of satisfactory quality by the assessing clinician, 41 patients under the government’s shielding program (identifying patients at the highest risk of COVID-19) received outpatient care from the safety of their home, and 218 consultations were carried out by a clinician working from home, highlighting the potential for digital dermatology assessments to provide a flexible alternative to traditional working patterns.

Of the 405 assessments, 292 (72.1%) concerned lesions, with the majority (241/292, 82.5%) referred for suspected cancer. Of these 292 lesions, 21 (7.2%) were booked for a web-based review, 139 (47.6%) were booked for a face-to-face review, 46 (15.8%) were directly booked for surgery, 81 (27.7%) resulted in discharge, and 5 (1.7%) were referred for photodynamic therapy. The remaining 113 (27.9%) assessments were for inflammatory dermatoses. Of these dermatoses, 45 (39.8%) were recommended for a web-based follow-up, 51 (45.1%) were recommended for a face-to-face review, 8 (7.1%) resulted in discharge, and 9 (8%) were referred for further investigations or treatments (Table 2). The majority of those needing a face-to-face review (137/190, 72.1%) were scheduled for a routine follow-up, although 27.9% (53/190) did require an urgent one-stop review for the confirmation of lesion diagnosis (including patients whose submitted images were unsatisfactory).

Additional information was acquired in 1 health board regarding histological diagnoses in 42 patients who were directly referred for biopsy or surgery following their assessment. This showed that 3 melanomas and 8 nonmelanoma skin cancers had been identified and treated.

Consultations in 1 health board were timed by using a stopwatch. The mean time for a total of 312 timed digital assessments was 10 minutes, whereas equivalent face-to-face consultations averaged 13 minutes. The time saving of digital consultations points to efficiency gains as well as the potential to increase available capacity and free up face-to-face appointments for those with complex care needs.

Feedback surveys indicated that satisfaction was high, with 82.1% (92/112) of respondents across both boards reporting ease of use. Further, 42% (47/112) reported that they would have normally needed to take time off work to attend a face-to-face appointment, while 21% (24/112) would have needed to travel for greater than 30 minutes to reach their hospital. Patient comments were generally positive, with many reporting that the reduced need for travel and time off work was a key benefit. Some patients reported technical difficulties, of which many have been subsequently improved after further development of the software. Newly referred patients were more likely to report that they would like more open dialogue with a clinician. Avoiding unnecessary hospital visits reduces the carbon footprint of the NHS and its contribution to the current climate emergency. During this evaluation, a total of 5758 km of patient travel was avoided through the use of digital assessments. This is equivalent to avoiding 719 kg of vehicle carbon dioxide emissions.