Primary Care Provider and Imaging Technician Satisfaction with a Teledermatology Project in Rural Veterans Health Administration Clinics

Abstract

Objective: Assessment of a multisite rural teledermatology project between 2009 and 2012 in four Pacific Northwest states that trained primary care providers and imaging technicians in state-of-the-art techniques of telemedicine. Materials and Methods: In 2012, we assessed provider and imaging technician acceptability and satisfaction with a 32-item survey instrument based on the Patient Satisfaction Questionnaire developed by Ware et al. (Eval Program Plann 1983; 6:247–63) and modified for telemedicine by Kraai et al. (J Card Fail 2011; 17:684–690). Survey questions covered eight satisfaction domains: interpersonal manner, technical quality, accessibility, finances, efficacy, continuity, physical environment, and availability. Results: Overall, 71% of the primary care providers and 94% of the imaging technicians reported being satisfied or extremely satisfied with the teledermatology project. Most (95%) providers found the continuing education classes on dermatology diagnosis and treatment topics useful, and 86% reported teledermatology was a good addition to regular patient services. Most (97%) of the imaging technicians were satisfied with the ability of teledermatology to improve the description of dermatology conditions using images of the lesions or rashes, and 91% were satisfied with the convenience of teledermatology. Challenges reported by both providers and imaging technicians include an increase in workload due to more patient visits related to dermatology care and limited information technology support. Conclusions: Given the Veterans Health Administration's initiatives to promote accessible health care to underserved Veterans using telehealth, these findings can inform future program designs for teledermatology.

Introduction

The advent of telemedicine programs is changing the current practice patterns of healthcare, especially for patients in underserved and hard-to-access areas, such as rural healthcare clinics.¹ Telemedicine utilizes technology to expand access to specialty care, such as dermatology, into these underserved areas. Keys to successful telemedicine programs include organizational structure, training, education, accurate technology, participant buy-in, and satisfaction with care.^2
–4 Teledermatology has been found to have equivalent diagnostic accuracy to traditional face-to-face care, in part because of digital cameras with high-resolution photographic quality, available electronic medical records, and standardized consult protocols.^5,6 Aside from advances in technology, the success of teledermatology programs also depends upon the acceptability of this process by the patients and buy-in from the participants providing care.⁷ Collecting feedback on barriers and areas of satisfaction from stakeholders (including staff and providers) about piloted telemedicine and teledermatology programs has helped foster better designed programs that can be more successfully implemented.^7

–12

Satisfaction with medical care is a multidimensional concept, and surveys need to capture not only global satisfaction with care, but also satisfaction with different features of healthcare delivery system (provider interactions, access, equipment, privacy, etc.). To address this need, Ware et al.¹³ developed the Patient Satisfaction Questionnaire (PSQ) with multiple construct items grouped into broad domains corresponding to major characteristics of healthcare providers and services (interpersonal manner, technical quality, access, finances, efficacy, continuity, physical environment, and availability). This survey was found to have good reliability (Cronbach's alpha=0.72–0.92 over the domains for internal consistency) and construct validity for a variety of patient settings, including oncology,^14,15 physical therapy,¹⁶ and human immunodeficiency virus/AIDS patients.^13,17 As the field of telemedicine developed, the construct definitions within these domains were adapted to reflect the characteristics of this type of healthcare delivery and found to have good reliability and validity.¹⁸ Currently, there are no validated instruments to assess patient satisfaction specifically with teledermatology.¹⁹ Many studies reporting that patients are generally satisfied with care received by teledermatology programs have not used validated satisfaction domains either, instead relying on a limited number of items typically rated by Likert scales.^20

–24 One study that used domains originally defined by Ware et al.¹³ to assess patient satisfaction with teledermatology failed to report results by domain groups, making suggestions to improve teledermatology programs difficult.²⁵ A pilot study of 10 patients found good patient satisfaction over three domains (interaction, impact on daily life, and usability) and an 83% acceptability of teledermatology overall.¹⁹

Although there are many reports that patients are satisfied with the care provided by teledermatology programs, there is a scarcity of studies on provider satisfaction of teledermatology programs, and satisfaction of imaging technicians has largely been ignored in the literature. A study in 2004 found only 21% of general practitioners were satisfied with a teledermatology trial in the United Kingdom.²⁶ A survey of 18 physicians in the Israel Defense Forces reported 87% were satisfied, but this was only based on three nonvalidated questions about teledermatology.²⁷ Similar to the previous two studies, other reports of provider satisfaction ranging from 63% to 92% is based on descriptive questions, not satisfaction domains.^23,24,28

In May 2011, the Secretary of the Department of Veterans Affairs (VA) approved a major telehealth expansion initiative to expand the use of telemedicine for Veterans by 50% by 2016.²⁹ To assist in implementing these programs, it is important to know how acceptable these programs are for the staff participating in providing this type of care. The purpose of this article is to assess primary care provider (PCP) and imaging technician satisfaction with a store-and-forward teledermatology project at rural VA outpatient clinics across four Pacific Northwest states.

Materials and Methods

Setting

The data for this article were collected as part of the 3-year Veterans Integrated Service Network (VISN) 20 Rural Teledermatology Quality Improvement Project. A coordinating core at the VA Puget Sound Health Care System in Seattle, WA networked with 30 participating VA rural outpatient clinics and parent facilities across four Pacific Northwest states (Alaska, Idaho, Oregon, and Washington). From October 2009 to June 2012, 16,194 teledermatology consults were completed on 9,720 unique patients. This quality improvement project did not require human subjects approval.

Teledermatology Participants

The three types of teledermatology participants from which acceptability and satisfaction data was collected included (1) PCPs at rural clinics (MD, DO, advanced registered nurse practitioner, or physician's assistant), responsible for the initial patient assessment and follow-up, (2) the imaging technician at rural clinics, responsible for photographing the dermatology problem (rash, lesion, etc.) and submitting the imaging note with captured images attached, and (3) the patients receiving dermatology care at rural clinics. After the first year of the project, a random sample of patients was surveyed regarding their satisfaction with teledermatology, and these results are reported elsewhere.²²

Teledermatology Process

Our teledermatology process has four major components: (1) an asynchronous store-and-forward telehealth process, (2) monitoring and quality improvement using benchmarked standards for readers, providers, and imagers, (3) continuing education programs, and (4) assessment of the increasing independent scope of practice for providers and imaging technicians.^30
–32 The teledermatology referral begins when a skin condition is identified by the PCP. The imaging technician obtains digital images of the lesion(s) and uploads them, together with a brief imaging note outlining the pertinent clinical data, into the VA's computerized patient record system (CPRS). A consult request is generated and transmitted via CPRS to the teledermatology coordinating center in Seattle. The consult request is assigned to a participating board-certified dermatologist consultant. The dermatologist consultant enters the differential diagnosis, treatment plan, and PCP follow-up instructions into CPRS. The referring PCP is alerted to the completed consult and is expected to perform the recommended procedures, refer as appropriate for complicated procedures, and assume responsibility for all patient follow-up.

Among the unique components of this teledermatology project was an extensive training and continuing education program for both PCPs and imaging technicians. We were able to offer training sessions and weekly classes, in addition to an annual training course that were tailored to the different needs and expectations of providers or imaging technicians. The weekly classes (via conference calls and shared slideshows) covered a variety of dermatology topics, including diagnosis, writing patient care plans, treatments, proper follow-up, case reviews, and classes on the teledermatology consult process itself. Details of the educational program have been published elsewhere.³⁰ Participants also received dermatology training not normally provided for primary care. PCPs received hands-on surgical training for basic dermatology procedures, and imaging technicians were trained in assisting surgical procedures in addition to the standard teledermatology protocols and procedural training. Our teledermatology project also offered an extensive follow-up program typically not done in other teledermatology programs to assure that all patients received needed care. Details of the follow-up protocol and consults are provided separately.³² Most (68%) of the teledermatology requests were completed with one consult and did not require additional follow-up consults. Only 26% required an additional consult, typically for a follow-up of a biopsy result or for a medication with potential side effects, although 5% required more consults from our teledermatology consultants, typically to confirm treatment completion or discuss biopsy results.³² Once a recommended treatment plan was accepted by the local PCP, the patient care was then typically managed by the local rural primary care team and not the teledermatology consultants.

Survey Measures

As there are no validated survey instruments to assess teledermatology provider and imaging technician satisfaction, we based our quantitative survey on the validated PSQ originally developed by Ware et al.,¹³ which groups similar satisfaction items into seven satisfaction domains (see Appendix for full survey). Since the advent of telemedicine, the PSQ has been modified to reflect the new method of healthcare delivery.³³ For example, the domain for “continuity” was defined to measure the sameness of provider and/or location of care by Ware et al.¹³ For telemedicine, “continuity” was modified to measure care provided by telemedicine compared with face-to-face care.³³ We modified our “continuity” item to measure care provided by teledermatology compared with face-to-face care. We added two additional items (global satisfaction and “Teledermatology is a useful addition to primary care at my clinic”). Our 32 items were grouped into eight satisfaction domains: interpersonal manner (4 construct items), technical quality (8 items), accessibility (4 items), finances (3 items), efficacy (3 items), continuity (2 items), physical environment (6 items), and availability (1 item). In addition, we also asked about global satisfaction (1 item).

Data Collection

Providers and imaging technicians actively participating in the project were electronically sent our satisfaction survey as part of their continuing education classes during the last year of the 3-year project. Participants completed the survey and e-mailed their responses.

Analysis

Participants were asked to rank each of 32 statements relating to the teledermatology process according to how strongly they agreed or disagreed to each statement. Each statement is scored using a 5-point Likert-like scale, ranging from 1=strongly disagree to 3=no opinion to 5=strongly agree. Some items are worded on the survey so higher scores reflects dissatisfaction with teledermatology; thus these items were reordered in the analysis so higher scores reflect higher satisfaction (to be consistent with other items). This allowed us to combine item scores within domains to present summary results. If no significant differences were found using the 5-point scale, the two lower categories (strongly disagree and disagree) were combined into one category (disagree), which reflects areas of dissatisfaction, and the two higher categories (agree and strongly agree) were combined into one group (agree), which reflects areas of satisfaction. To assess if different factors within each domain affect satisfaction, responses to each item were compared. To assess if satisfaction varies collectively by each domain, the mean score for each domain is calculated from all items within each of the nine domains. As PCPs and imaging technicians have different roles in patient care and teledermatology responsibilities, the data are presented separately for these two groups. As the implementation of our teledermatology program was not uniform across the four states, we classified sites by the intensity of activity (mean number of teledermatology consults submitted per month). High-performing sites were defined as clinics that submitted at least 10 consults/month (the median number of consults/month for all providers), and low-performing sites submitted fewer than 10/month. Significance is assessed using a chi-squared test (for Fisher's exact test for small cell sizes) for discrete variables and a Student's t test for continuous variables. Values of p≤0.05 are considered statistically significant.

Results

Participants

Slightly more PCPs were female (57%), and nearly half had an MD or DO degree (Table 1). Most of the imaging technicians were female (76%), and technicians were typically LPNs, RNs, or health technicians. The site where providers and imaging technicians practiced was distributed over the four states. We had responders from 30 different sites (8 parent facilities and their associated rural outpatient clinics). Age and race data were not collected for the providers or imaging technicians. Of the 21 providers, 11 were worked at high-performing clinics (mean, >24 teledermatology consults/month), and 10 worked at low-performing sites (averaging 5 consults/month), as shown in Table 1 .

Table 1.

Characteristics of Surveyed Population

CHARACTERISTIC	PRIMARY CARE PROVIDERS (N=21)	IMAGING TECHNICIANS (N=34)
Gender
Female	12 (57.1)	26 (76.5)
Male	9 (42.9)	8 (23.5)
Education/degree^a
MD	6 (28.6)	0
Doctor of Osteopathic Medicine (DO)	4 (19.0)	0
Advanced registered nurse practitioner (APRN)	9 (42.9)	0
Physician assistant (PA)	2 (9.5)	0
Registered nurse (RN)	0	8 (23.5)
Licensed practical nurse (LPN)	0	13 (38.2)
Health technician	0	7 (20.6)
Medical assistant	0	5 (14.7)
Administrative assistant	0	1 (2.9)
Parent location (number of active outpatient clinics)
Anchorage, AK (5)	2 (9.5)	4 (11.8)
Boise, ID (3)	3 (14.3)	3 (8.8)
Portland, OR (4)	2 (9.5)	4 (11.8)
Roseburg, OR (5)	6 (28.6)	8 (23.5)
Seattle, WA (3)	2 (9.5)	2 (5.9)
Spokane, WA (2)	1 (4.8)	2 (5.9)
Walla Walla, WA (5)	3 (14.3)	8 (23.5)
White City, OR (3)	2 (9.5)	3 (8.8)
Time (months) in project	20.9±10.0^b	13.8±11.4
Degree of participation (mean number consults/month)
High-producing sites	24.4±13.7	27.8±17.0
Low-producing sites	5.0±2.9	4.0±3.4

Data are mean±standard deviation values or number (%) as indicated.

All imaging technicians were also certified teledermalogy imaging technicians.

p<0.05.

Response Rate

In total, 78 participants were sent surveys, and 21 of 30 (70.0%) PCPs and 34 of 48 (70.8%) imaging technicians completed the satisfaction survey. Significantly more nonresponding providers were male compared with those completing the survey (89% and 43%, respectively; p=0.04). There was no significant difference for imaging technicians by male gender for nonresponding versus those completing (23.5% and 35.7%, respectively). There were also no significant differences for nonresponders compared with those completing the survey for either providers or technicians by type of educational degree or clinic location (data not shown).

Global Satisfaction

When providers rated if they were satisfied with the overall teledermatology project, 38% strongly agreed, 33% agreed, 14% had no opinion, 14% disagreed, and no one strongly disagreed. When imaging technicians rated if they were satisfied, 68% strongly agreed, 26% agreed, 3% had no opinion, 3% disagreed, and no one strongly disagreed.

PCPs were generally satisfied overall (71.4%), whereas significantly more (94.1%) (p=0.02) of the imaging technicians were generally satisfied (Table 2). Although providers were active in the project for a significantly longer time compared with imaging technicians, this was not associated with an increase in global satisfaction ratings. The average time in the project for those who were generally satisfied was 16.5±11.4 months compared with 17±11.8 months for those who were not satisfied. Satisfaction with the teledermatology program was highly influenced by the degree of participation of the clinic where the PCP and the imaging technician worked. Most of the providers (91%) reported being satisfied or highly satisfied with teledermatology if they worked at a high-producing site (averaging 24 consults/month). In contrast, significantly fewer providers (50%) (p=0.04) were satisfied if they were had less experience with teledermatology (averaging 5 consults/month at low-producing sites). Global satisfaction did not significantly differ for imaging technicians at high- versus low-producing sites.

Table 2.

Frequency Agreeing with Satisfaction Domain Statements for Primary Care Providers and Imaging Technicians Participating in the Veterans Integrated Service Network 20 Rural Teledermatology Project (2009–2012)

TELEDERMATOLOGY SATISFACTION ITEM	PRIMARY CARE PROVIDERS (N=21)	IMAGING TECHNICIANS (N=34)
Global satisfaction with teledermatology
Overall, I am satisfied with teledermatology.	15 (71.4)	32 (94.1)^a
Interpersonal manner
Good understanding of dermatology care needed	14 (66.7)	31 (91.2)^a
Privacy is protected.	14 (66.7)	24 (70.6)
Lack of physical contact acceptable	11 (52.4)	25 (73.5)
Patient follow-up acceptable	9 (42.9)	24 (70.6)^a
Technical quality of care/competency
Can describe the condition better with images	16 (76.2)	33 (97.1)^a
Can monitor patient's condition well	11 (52.4)	26 (76.5)^b
Future standard of healthcare	12 (57.1)	29 (85.3)^a
A good addition to regular patient services	18 (85.7)	30 (88.2)
Continuing education program on dermatology topics useful	20 (95.2)	30 (88.2)
Intermediate surgical training useful	14 (66.7)	17 (50.0)
Annual training program useful	14 (66.7)	21 (61.8)
Monthly follow-up reports useful	14 (66.7)	22 (64.7)
Accessibility
Saves time	13 (61.9)	26 (76.5)
Increases patient access to care	16 (76.2)	30 (88.2)
Easier for patient to contact provider/imager	9 (42.9)	15 (44.1)
Had sufficient dedicated time	9 (42.9)	15 (44.1)
Finances
Saves money for patient	15 (71.4)	28 (82.4)
Cost of co-pay acceptable	4 (19.1)	14 (41.2)^b
Reduces cost for the VA	11 (52.4)	25 (73.5)
Efficacy
Believes it improves patient's health	14 (66.7)	32 (94.1)^a
Time for consult completion acceptable	17 (80.9)	30 (88.2)
Useful addition to primary care	13 (61.9)	26 (76.5)
Continuity
Prefer to provide patient care by teledermatology rather than face-to-face	12 (57.1)	21 (61.8)
Prefer process of teledermatology visit over face-to-face visit	5 (23.8)	11 (32.3)
Physical environment
Equipment easy to use	14 (66.7)	28 (82.3)
Convenient form of healthcare delivery	14 (66.7)	31 (91.2)^a
Patient confidentiality not threatened	14 (66.7)	29 (85.3)
Can always trust equipment to work	10 (47.6)	25 (73.5)^a
No problems with computers or information technology	7 (33.3)	13 (38.2)
No problems with provider or imager notes	11 (52.4)	27 (79.4)^a
Equipment availability
No problems getting equipment/supplies	9 (42.9)	22 (64.7)

Data are frequency (%).

p≤0.05, compared with primary care providers.

For trend, 0.05<p<0.1.

Satisfaction Domains

Satisfaction with each of the 32 items for providers and imaging technicians is shown in Table 2 grouped by domains. The three individual factors associated with a highest frequency of satisfaction with the teledermatology project for providers included having access to continuing education classes on dermatology diagnosis and treatment topics (95%), the ability to add dermatology care to their regular patient services (86%), and rapid time for consult completion (81%). Imaging technicians were most satisfied with the ability to improve the description of dermatology conditions using images of the lesions or rashes (97%), the ability to document the type of patient care needed (91%), and that teledermatology is a convenient form of healthcare delivery (91%). Most imaging technicians (94%) reported they believe teledermatology has a role in improving patient health.

Interpersonal Manner Domain

When major characteristics of healthcare staff and services are grouped into separate domains, patterns of satisfaction become apparent. As shown in Table 2 , not all constructs within a specific domain are associated with the same degree of satisfaction or acceptability. Within the interpersonal manner domain (which assesses provider–imager interactions with patients), providers were most satisfied with the understanding of the type of patient care needed (67%) and the ability to protect a patient's privacy (67%) but were less satisfied with patient follow-up (43%). Imaging technicians were mostly satisfied (≥71%) with how teledermatology allows them to interact with patients.

Technical Quality of Care/Competency Domain

Within the technical quality of care domain (which assesses the competency of providers to diagnose and treat patients remotely), both providers and imaging technicians were largely satisfied (≥67%) with their training and their ability to detect and care for dermatology conditions. Providers were most satisfied with the continuing education program, which included classes on diagnosis and treatments (95%), but were least satisfied with the ability to monitor the patient's condition (52%). Imaging technicians were most satisfied with the ability to describe the patient's condition using images (97%) but least satisfied with the usefulness of the assisting intermediate surgical training (50%). This dissatisfaction may be associated with the degree of participation for imaging technicians. More imaging technicians reported being dissatisfied with the surgical training if they were working at a low-producing site (63%), whereas of technicians working at high-producing sites, only 39% were dissatisfied with the surgical training.

Accessibility Domain

Within the accessibility domain (which assesses factors relating to the ability to receive medical care), providers agreed that teledermatology increases patient access to care (76%) and may save time (62%), but only 43% believed teledermatology made it easier for patients to contact their providers. Less than half (43%) of providers reported having sufficient amount of dedicated time for the teledermatology process. Imaging technicians reported similar findings.

Financial Domain

Within the financial domain (which assesses factors relating to costs), most providers and imaging technicians agreed teledermatology saves patients money (71% and 82%, respectively), but providers were less satisfied with the amount of co-payments and ability to reduce costs for the VA compared with imaging technicians. Patients typically pay a higher co-pay ($50) for a specialty visit such as teledermatology, whereas the co-pay for a primary care visit is typically lower ($15).

Efficacy Domain

Within the efficacy domain (which assesses the results or outcomes of teledermatology care), providers were most satisfied with the rapidity of consult completion (81%), and 88% of the imaging technicians agreed. The average time for a teledermatology consult was 1.7 days.³² When asked if teledermatology was a useful addition to their primary care practice at their clinic, 62% of providers and 76% of imaging technicians agreed. More imaging technicians reported they believe teledermatology improves a patient's health (94%) compared with providers (67%). The belief that teledermatology improves patient health is more common in providers with more experience with teledermatology. Most (89%) of providers at high-producing sites reported their belief that teledermatology improves their patient's health compared with fewer providers working at low-producing sites (40%) (p=0.015).

Continuity Domain

Within the continuity of care domain (which assesses if similar care is received compared with traditional face-to-face visits), 57% of the providers and 62% of the imager technicians preferred to provide patient care via teledermatology versus face-to-face care. Only one-third of providers and imaging technicians preferred the process of teledermatology care over traditional face-to-face care, which may indicate that 66% prefer the more familiar charting practices involved in traditional patient care compared with learning the new teledermatology consult protocols.

Physical Environment Domain

Within the physical environment domain (which assesses the features of teledermatology equipment and the work environment at remote sites), providers and imaging technicians were generally satisfied, but both types of participants were least satisfied with computer and information technology problems.

Equipment Domain

Within the equipment availability domain (which assesses the presence of needed teledermatology equipment), over half of the providers reported problems with obtaining equipment (mostly nondisposable surgical tools), whereas a minority (35%) of the imaging technicians had problems obtaining cameras and card readers.

Global Domain Trends

When satisfaction items are summarized within the nine domains, PCPs were significantly less satisfied than imaging technicians across the six satisfaction domains (Fig. 1). The greatest differences between PCPs and imaging technicians was the availability of teledermatology equipment (fewer providers had access to dermatoscopes and nondisposal surgical equipment, whereas most imaging technicians have access to cameras). More imaging technicians perceived the financial burden was acceptable to patients, whereas fewer providers agreed. Providers were less satisfied with the physical environment of the teledermatology project (equipment easy to use, patient confidentially maintained, and convenience). Providers were less satisfied within the accessibility domain, mainly because of difficulties in scheduling imaging technicians and not having sufficient dedicated time during teledermatology patient visits. Overall, imaging technicians achieved higher maximum global satisfaction scores compared with PCPs.

Fig. 1.

Mean satisfaction domain scores for primary care providers and imaging technicians participating in the Veterans Integrated Service Network 20 rural teledermatology project (2009–2012).

Discussion

This article examined the satisfaction of PCPs and imaging technicians with our teledermatology project and identified factors associated with satisfaction of teledermatology care. Most (86% of our 55 surveyed PCPs and imaging technicians) were satisfied with the teledermatology project overall. The success of teledermatology not only depends on the successful implementation of an integrated system of computerized medical records, imaging procedures, and trained personnel, but also requires patients and healthcare providers are satisfied with this innovative process of healthcare. We previously reported 77% of patients receiving dermatology care with our teledermatology project were satisfied or highly satisfied with their care,²² and it is reassuring that 86% of our providers and technicians were also satisfied with our teledermatology project. Benefits of our teledermatology project reported by the patient satisfaction survey (shorter wait times, belief that their dermatology condition was properly treated and adequate follow-up was received)²² were also reflected by the results of the provider/technician satisfaction survey reported in this article. Providers and imaging technicians also reported rapid consult times and belief that proper patient dermatology care was being provided.

To our knowledge, this is the first article to evaluate the multidimensional concept of satisfaction of teledermatology providers and imaging technicians using modified domains from a patient satisfaction instrument. Although the PSQ was not specifically designed to measure provider satisfaction with teledermatology, it has construct validation across a wide range of patients and disease conditions.^{13
–15,17,34} Satisfaction items from this survey tool have been successfully adapted to measure patient satisfaction with telemedicine care.^18,33 Most studies of patient satisfaction with teledermatology programs have not utilized the multidimensional concept of domains of satisfaction, relying instead on global satisfaction questions,^22
–24 and only two studies utilized satisfaction domains for their analysis of patient satisfaction.^19,25

In contrast, the satisfaction of PCPs and imaging technicians has not been as thoroughly explored. Most studies of provider satisfaction have relied on a global statement of satisfaction.^26,27 Klaz et al.²⁷ reported 87% of 18 providers involved in an Israel military teledermatology program were “satisfied.” Weinstock et al.²³ reported 63% of 19 providers rated teledermatology “excellent to good.” Whited et al.²⁴ reported 92% of 53 providers at the Durham, NC Veterans Administration Medical Center were satisfied with the store-and-forward teledermatology program. Frühauf et al.¹⁹ piloted a satisfaction survey grouping 10 items into two domains (diagnostic validity and usability) but only tested the survey with two dermatologist consultants and did not survey PCPs or imaging technicians.

Examining trends found in the domains in our survey, we noted both types of participants (PCPs and imaging technicians) were extremely satisfied with teledermatology overall, were pleased with their ability to provide local dermatology care at their rural clinics, and found the equipment was reliable and the consult process rapid. In general, imaging technicians reported higher levels of satisfaction over all domain categories compared with PCPs.

Most imaging technicians (94%) and providers (67%) believed teledermatology improves patients' health, but direct evidence was not collected as part of this survey to support this statement. We determined from a survey of 615 Veterans in our catchment area that 23% of those needing dermatology care did not receive it prior to starting our teledermatology project and that 9,720 Veterans received teledermatology consults during our project.

When asked to choose between care delivered using teledermatology or the more traditional face-to-face visit, 57% of our PCPs and 62% of the imaging technicians preferred teledermatology. Whited et al.²⁴ reported 84% of 53 providers surveyed preferred teledermatology, and Pak et al.⁵ reported 70% of providers preferred teledermatology over face-to-face patient care. In contrast, most reported the process of teledermatology visits (which involve submitting consults, uploading images, etc.) is technically more challenging than face-to-face visits, and fewer were satisfied with the additional workload teledermatology may entail.

Factors associated with successful teledermatology programs in the literature include a well-established infrastructure, training programs, reliable equipment, and adequate technical support.^12,19 In our survey population, factors associated with provider and technician satisfaction included the usefulness of the continuing education programs on dermatology diagnostic methods and treatments, the ability to describe the patient's dermatology conditions accurately with the addition of images and descriptive imaging technician notes, increased access to rapid patient care for Veterans, and ability to add dermatology care to their local patient services. The weekly educational classes and skills training programs allowed nondermatologist providers to be trained to perform basic dermatology procedures. At the beginning of our project, most providers did not perform dermatology procedures at their local clinics (only 33% did excisions, 29% did punch biopsies, 14% did electrocautery, and 9% did shave biopsies), but by the end of the second year of participating in our teledermatology project, 100% performed these procedures at their own clinics.³⁰ By the end of the first year of weekly classes, providers and imaging technicians also showed a significant increase in knowledge scores about dermatology conditions (1.2-fold [p=0.04] and 1.9-fold [p<0.001] increase in mean test scores, respectively).³⁰

Many of the challenges of teledermatology programs may be linked to the tension due to the necessity to provide primary care and manage large patient care panels, while at the same time providing specialty care such as teledermatology. In a study by Armstrong et al.,³⁵ 10 referring providers identified three areas they wanted improved in their teledermatology program: improved workflow, better communication with dermatology consultants, and a faster turnaround for referrals. In our program, providers and imagers were satisfied with our rapid turnaround and easy communication via telephone or e-mails, but also found increased workflow to be troublesome. Future teledermatology and other telemedicine programs need to recognize this challenge and provide sufficient workload space or otherwise incentivize PCPs to participate in specialty care programs. Not all healthcare practices have the advantages of shared secure electronic medical records with access from remote sites and the ability to adjust workload to allow providers and imaging technicians time to perform teledermatology services. Other teledermatology programs have overcome these limitations by transmitting images to dermatology consultants using cell phones or by having more of a triage role in patient care.^10,36,37

Implementation of teledermatology was not consistent across all of our sites. Some clinics were successful in implementing the project and submitted numerous consults per month, whereas others had difficulty getting the teledermatology process to function smoothly. Although the reasons for low- and high-performing sites will be explored in a future article, in general, low-performing sites were small clinics, had small staffs, and were not supported by their local administration. Although it took a great deal of effort to start teledermatology at multiple clinics, we were surprised by the enthusiasm and motivation of providers and technicians. They recognized the need for dermatology care at their local clinics, and because of the services provided (dermatologist consults, educational classes, and skills training), they generally were very helpful assisting the implementation of the teledermatology program at their clinics, even though it required extra work for them. Financial incentives may be more applicable to other types of healthcare systems to promote participant buy-in but was not a major motivator for our providers, as we only provided small salary offsets and specialized dermatology equipment to all the sites.

Barriers to satisfaction with teledermatology identified in literature include delayed or absent follow-up protocols³⁸ and increased workload due to the influx of new patients with dermatology conditions.^23,39 Our providers and technicians also report not having sufficient dedicated time to complete teledermatology processes and provide patient care because of increased patient demand created by the availability of dermatology services at these rural settings. In addition, 64% report having issues with information technology support. In contrast to reports in the literature, 67% of providers and 65% of imaging technicians were satisfied with patient follow-up, which might be due to our collaborative follow-up protocols.³²

Our survey had several limitations. The survey questions have not been tested for reliability or validity in the population of PCPs and imaging technicians for teledermatology. The questions are based on a standard, validated, and reliable instrument for patient satisfaction modified for telemedicine, but this survey needs to validated in the teledermatology provider and imaging technician populations in future studies. Our study has good content validity, as the questions were vetted by several dermatologists and providers, and the questions reflected their concerns and areas of satisfaction. The satisfaction domains used in our survey were the ones recommended by the review of Kraai et al.³³ for teledmedicine satisfaction surveys. Another limitation to quantitative survey questions includes the interpretation of what specific terms mean to the participants. A provider's view of being satisfied with components of the teledermatology program may be different than the imaging technician's viewpoint. This is one of the reasons we presented the results stratified by the type of participant and may be one reason why results differ by participant type. In addition, global satisfaction responses may be linked to satisfaction with the process and/or to the outcome achieved. In an effort to tease out these differences, questions were asked across different domains of the teledermatology project. Another limitation is the generalizability of our findings because the results are based on providers and imaging technicians obtained from VA facilities. Other healthcare systems with less shared electronic communications or limited financial resources may find this type of program with continuing education components and shared follow-up responsibility to be too arduous. However, Krupinski et al.³ reported the key to success of any telemedicine program is training and education.

We demonstrated participants in our teledermatology project (PCPs and imaging technicians) have high levels of satisfaction with most components of teledermatology, but continuing challenges include increased workload for providers and adequate technology support.

The implications of the high level of acceptability of teledermatology for providers and imaging technicians provide support and suggestions for future teledermatology programs, which may improve access to specialized healthcare in underserved rural locations.

Footnotes

Acknowledgments

The authors acknowledge the rural primary care providers and imaging technicians in VISN 20 who dedicated their time and energy to this project in this project. This material is based on work supported by the Office of Rural Health, Veterans Health Administration, U.S. Department of Veterans Affairs, and support from VA Health Services Research and Development for the Senior Career Scientist Award RCS 98-353 to G.E.R.

Disclosure Statement

No competing financial interests exist.

Appendix

McFarland Teledermatology Provider and Imaging Technician Satisfaction Survey

CHECK ONE RESPONSE BOX FOR EACH QUESTION PLEASE:	STRONGLY DISAGREE (1)	DISAGREE (2)	NO OPINION (3)	AGREE (4)	STRONGLY AGREE (5)
1. I can get a good understanding of the dermatology care needed by my patients electronically.
2. Teledermatology can violate patient's privacy.
3. I can describe the patient's problem well enough using the electronic medical record system.
4. The use of the necessary equipment (camera/computer) seems difficult to me.
5. I prefer to provide care face-to-face rather than with teledermatology.
6. Teledermatology improves my patient's health.
7. Teledermatology saves time.
8. Teledermatology saves money for the patient.
9. The cost of co-payments for teledermatology is acceptable.
10. Using teledermatology, I can monitor my patient's condition well.
11. I don't like that there is no physical contact between the patient and the dermatologist.
12. Teledermatology is a convenient form of healthcare delivery.
13. Teledermatology will be a standard way of healthcare delivery in the future.
14. Teledermatology can be an addition to the regular care my patients receive.
15. Telederm reduces costs for the VA.
16. Teledermatology does not increase patient's access to care.
17. The use of technology does not threaten the confidentiality of my patient's data.
18. I prefer teledermatology to the typical face-to-face visit.
19. Teledermatology makes it easier for the patient to contact me.
20. I cannot always trust the equipment to work.
21. I did not have problems getting equipment (camera, surgical kits, lamps, etc.).
22. I did not have problems with IT (computer software, access codes, image uploads, sanctuary approval, etc.).
23. I had sufficient dedicated time to do the teledermatology initial visit (patient history or images).
24. I was satisfied with time it took for consult requests to be returned by the dermatology readers.
25. I had no problems with provider notes or image notes.
26. I did not find patient follow-up to be a problem.
27. I found the continuing education program useful.
28. I found the intermediate surgical training useful.
29. I found the Annual Training Session in June useful.
30. I found that the monthly follow-up reports were useful to me.
31. I found teledermatology to be a useful addition to primary care at my clinic.
32. Overall, I am satisfied with the teledermatology program.
If you have any additional comments, please fill in below:

Note that for coding, reverse the values for the following questions (Questions 2, 4, 5, 11, 16, and 20), so higher values reflect more positive attitudes similar to other questions.

IT, information technology; VA, Veterans Affairs.

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