Global teledermatology

Telemedicine is the delivery of health care services between two remote locations through information and communication technologies to improve a patient’s health condition. It is a tool to increase access to quality care services for patients in both developing and developed countries in any situation in which there is a barrier to receiving treatment [1]. There are generally two methods of telemedicine delivery: store-and-forward and live-interactive. The store-and-forward modality involves the transfer of digital images with relevant patient information through email or a web-based platform to a specialist in a remote location for consultation. In liveinteractive telemedicine, the patient and/or their healthcare provider meet with the consulting specialist and interact in real time through videoconferencing. Since its inception about 40 years ago in US hospitals, telemedicine services have expanded across the world and now include many different specialties [2,3].


Introduction
Telemedicine is the delivery of health care services between two remote locations through information and communication technologies to improve a patient's health condition. It is a tool to increase access to quality care services for patients in both developing and developed countries in any situation in which there is a barrier to receiving treatment [1]. There are generally two methods of telemedicine delivery: store-and-forward and live-interactive. The store-and-forward modality involves the transfer of digital images with relevant patient information through email or a web-based platform to a specialist in a remote location for consultation. In liveinteractive telemedicine, the patient and/or their healthcare provider meet with the consulting specialist and interact in real time through videoconferencing. Since its inception about 40 years ago in US hospitals, telemedicine services have expanded across the world and now include many different specialties [2,3].
Dermatology is particularly well suited for telemedicine because it is a visual specialty. Teledermatology, defined as the remote delivery of dermatological services and clinical information using telecommunications technology, is the second most developed telemedicine service area globally, behind teleradiology [1,4]. Teledermatology is a rapidly growing field due to technological advancements and its potential to address the shortage of dermatologists in rural and underserved communities. The most recent data published on physician needs assessment estimates that the ideal ratio of dermatologist to population ratio is 1:30,000 [5]. This need is largely unmet across the globe, as the International Foundation for dermatology estimates that 3 billion people in 345 developing countries lack basic care for skin diseases [6]. Table 1 demonstrates the disparity in dermatologists around the world [7].
Much of the current literature on teledermatology solely addresses its validity in healthcare delivery, evaluating diagnostic accuracy, reliability, and patient satisfaction in multiple short-term studies. However, there are few published works on established programs, pilot projects, or feasibility studies in teledermatology, which would indicate that a country has an existing infrastructure and technology that can develop into a permanent program. To the best of our knowledge, the prevalence and locations of teledermatology programs have not been assessed globally. The objective of this paper is to identify established and pilot teledermatology programs across the world.

Methods
This study looked at the 194 member states recognized by the World Health Organization. We searched the PubMed MEDLINE [in All Fields] and Scopus databases [in Article title, Abstract, and Keywords] for teledermatology programs in each country from 1995 to present. In our search, we used the terms "teledermatology AND [country]" and "telemedicine OR telehealth AND dermatology AND [country]". Only articles in English with titles and abstracts that were published online and in print were considered for inclusion. Search results were then screened and studies were excluded based on title and/or abstract if the study solely measured outcomes of diagnostic reliability and accuracy of teledermatology vs. face-to-face consultation, patient satisfaction with the program, or cost-benefit analysis. All articles with descriptive studies of established programs, pilot studies, and feasibility studies were reviewed. The reference lists of identified studies were also searched for further relevant studies.

Results
Of the 194 countries searched in the literature, 81 were found to have an established teledermatology program, a telemedicine program that includes dermatology, a pilot project in teledermatology, or a feasibility study in teledermatology. The study found 153 total programs globally. Among both active and non-active teledermatology programs, a majority (86%) of programs used store-and-forward as the method of delivery. The remainder of programs used live-interactive, a combination, or an unknown method of delivery.
There was a total of 133 sustained teledermatology programs or active pilot projects around the globe (Figure 1). These programs include store-and-forward and live-interactive modalities delivered through government national health systems and other government initiatives, commercial organizations for consumers, and nonprofit/charitable organizations. In addition, military use of ongoing teledermatology programs was also found in the literature review and included in this paper. 17 countries performed feasibility or pilot studies, indicating the presence of technology and teledermatology infrastructure which is presented below (Table 2).
Of 131 countries searched in the study that did not have mention of a teledermatology program, a majority (80%) were in the bottom third in terms of population rank [60] Teledermatology programs in developing countries were mainly delivered through non-profit/charitable humanitarian health networks with volunteer physicians and a simple, web based platform or email for communication between the consultee and specialist (Table 3).

Discussion
According to a 2011 WHO survey on global telemedicine, teledermatology is more established in high-income group countries, where the main challenges include legal issues with patient privacy and confidentiality, limited reimbursement for practitioners, and competing health system priorities. Developing countries are more likely to face larger barriers to implementation such as resource issues, high costs, underdeveloped infrastructure, and lack of technical expertise [1]. Therefore, teledermatology has been adopted more for use in the developed world where it is seen as a cost-effective way to increase access to care for patients who cannot travel or have inadequate insurance [63]. However, it has great potential to address challenges faced to those in the developing world that are deprived of even basic health care access.
Although developing countries with a high burden of disease and limited resources or access to specialists can arguably benefit the most from teledermatology, many of these countries lack a reliable power supply and cannot afford any sophisticated software needed for a telemedicine exchange. Physicians and government health policy makers in these regions that have very little to spend on healthcare per person may doubt the need for expensive teledermatology equipment when that money could go to much needed drugs for skin diseases. Additionally, with the exception of leprosy and other infectious diseases that affect the skin, dermatologic conditions are given little importance in developing regions that suffer from major lethal health conditions such as malaria, tuberculosis, and HIV/AIDS [30].
Recognizing this dilemma faced by developing countries, humanitarian health networks have developed easy-to-use, open access platforms for underserved regions around the world. The only requirements for participation in the teledermatology programs are access to the internet and a device to send and upload pictures (digital camera or phone). Figure 2 shows a simple schematic of the information exchange in these health network teledermatology programs.
These telehealth networks have been proven to be an efficient method of consultation. A prospective review of email consultations between referring doctors and consulting specialists of Swinfen Charitable Trust operations showed a median time of 1.5 days from a referral to a definitive reply. A similar study conducted on Telederm showed that 60% of requests were answered within one day, 35% within one week, and 4% in two weeks during the first two years of operation. Because the only requirements for participation in the teledermatology programs are access to the internet and a device to send and upload pictures (digital camera or phone), these teledermatology programs have been able to penetrate many developing countries. From 2000 to 2015, internet usage in underdeveloped regions such as Africa, Latin America, and the Middle East have exceptionally grown (Table 4) [64]. Additionally, access to mobile services in the developing world has outpaced the rate at which much of the population is gaining access to basic services such as banking, sanitation, and electricity [65]. With internet and mobile phone usage becoming increasingly available in all areas of the world, these telehealth networks have the potential to expand to more developing countries.
This review was done to provide a comprehensive overview of the prevalence and locations of teledermatology programs globally and has some limitations. New teledermatology programs and pilot projects without published data could exist and were not included in this paper. Articles published in different languages were not reviewed which could possibly explain the lack of teledermatology programs found in    non-English speaking regions. Also, because a majority of the countries without a known teledermatology program were the least populous, it is possible that there is not a significant need for dermatologists in these areas.

Conclusion
In areas that do not have access to dermatologic care due to distance or simple manpower, teledermatology seems like an ideal solution to reach the underserved. However, many factors such as cost, lack of access to modern communication, and underdeveloped infrastructure serve as major obstacles to its widespread use. Teledermatology has been demonstrated to be feasible and diagnostically accurate in many different settings. Although teledermatology programs are more prevalent in developed countries, non-profit/charitable humanitarian health networks have been able to serve many developing regions with a free and an easy-to-use interface. Future efforts need to focus on expanding the outreach of these existing humanitarian telehealth networks and/or simple, inexpensive technology and strategies to sustain programs in developed countries and developing countries that suffer from a high burden of disease with limited resources.