Teledermatology in times of COVID‐19

Abstract Remote consultations are likely to grow in importance in the following years, especially if the coronavirus disease 2019 (COVID‐19) pandemic continues. Patients’ opinions on teledermatology have already been analyzed, but a current analysis during the COVID‐19 pandemic is lacking. The purpose of this survey was to investigate the satisfaction of patients who had received dermatological advice via telephone during the COVID‐19 pandemic and to analyze their general opinion about eHealth as well as possible limitations for a broad implementation. Ninety‐one patients managed in the dermatology department using telephone consultation during the COVID‐19 pandemic were interviewed. An anonymous questionnaire, including the established quality of life questionnaire (Dermatology Life Quality Index [DLQI]), was used. It was found that men were more satisfied with telephone consultations than women (p = 0.029), educational level and age did not correlate with satisfaction (p = 0.186 and 388, respectively), and the longer the waiting time for a telephone consultation, the lower the satisfaction (p = 0.001). Grouped analysis of all participants showed that the majority (54.0% n = 38/71) were “very happy” with the telephone consultation. Higher disease burden (DLQI) was associated with lower satisfaction (p = 0.042). The main stated reasons for using telemedicine were shorter waiting times (51.6% n = 47/91) and no travel requirement (57.1% n = 47/91). Almost one‐quarter (23.1% n = 21/89) of patients would use teledermatology in the future, 17.6% (n = 16/89) would not, and 57.1% (n = 51/89) would only use it in addition to a traditional consultation with personal contact. In conclusion, most patients in the study group still preferred traditional face‐to‐face medical consultations to telephone consultations, but also desired an add‐on telemedical tool. Dermatological care using more modern telemedicine technologies than telephone conferencing is needed to better address patients’ desires, especially in times of the COVID‐19 pandemic.


| INTRODUC TI ON
In the last decade, eHealth services have evolved and become more relevant for clinical health-care systems over the world. In 2015, the German eHealth act was adopted and thus integrated technologies, such as electronic health insurance cards, electronic patient records, medication summary, and video consultations in the German legislation. 1 Nevertheless, to date only 50% of German hospitals have electronic patient records and only 13% provide electronic discharge letters for outside practitioners via portal or mail. Electronic communication with patients is used by 19% of German doctors in private practice and is thereby slightly more developed. Overall, Germany lags behind Austria and Switzerland in eHealth development, which may be due to missing incentives, an eHealth law focusing on the outpatient sector rather than on the inpatient sector, and very stringent data protection laws. 2 However, as the technological progress and the evolution of mobile phones proceeds rapidly, the perceived utility of telemedicine is now increasing and eHealth is becoming increasingly relevant for daily clinical business. 3 Teledermatology was one of the first telecommunication technologies to be implemented in 1995 and significantly grew in the last decade. 4 One can distinguish between two types of teledermatology services: the store-and-forward method or the live-interaction method. The store-and-forward method is more common as it is easily manageable concerning time issues and practicable across different time zones. In contrast, the live-interaction method requires a significant bandwidth, especially for video consultations, but may save time through direct interaction. 5 The diagnostic and management decisions are reliable and accurate in both methods, and clinical outcomes are similar to those of standard care. [6][7][8][9][10][11] The main barriers for a broad implementation of eHealth and telemedicine were summarized by Kruse et al. 12 in 2018 and included barriers for organizations, such as costs, reimbursement, legal liability, as well as barriers for patients, such as age and level of education, as well as barriers for staff and programmers such as technical challenges and a resistance to change. In this eHealth survey, we analyzed the opinion and satisfaction of patients consulted via telephone for skin problems during the coronavirus disease 2019 (COVID-19) pandemic.

| ME THODS
After ethical approval by the local ethics commission was obtained, the survey was sent to 340 patients, who had used telephone con-

| Demographics
A total of 91 patients took part in our survey ( Table 1) Regarding the DLQI of participants, the minimum was 0 and maximum 27 points. The mean was 6.19 and median 4.00 (standard deviation, 6.540).

| Satisfaction
In our survey, men were more satisfied with the telephone consultation than women (p = 0.029). Education level and age did not correlate with satisfaction (p = 0.186 and 0.388, respectively). The longer the waiting time for a telephone consultation, the lower the satisfaction (p = 0.001). The higher the disease burden (DLQI) the lower the satisfaction with the telephone consultation (p = 0.042).
Whenever the help was judged as sufficient, the satisfaction was higher (p < 0.001).

| Telemedicine in the future
The higher the level of education as well as the amount of free time spent with digital media, the more telemedicine was perceived as

| DISCUSS ION
The present study demonstrates that telephone contact as a mode of telemedicine in times of the COVID-19 pandemic satisfies a majority of dermatology patients, predominantly due to shorter waiting times and the absence of travel time or expenses. In the literature, the definition of satisfaction is not consistent across surveys and therefore difficult to compare. 14 Moreover, only one study in the last 10 years exclusively addressed patient satisfaction related to liveinteraction teledermatology. 15 This study showed that teledermatol- In our patient collective, one-third could be sufficiently helped with the telephone consultation and nearly half of the patients were "very happy" with the telephone consultation. In contrast to the liveinteraction method of teledermatology, most studies conducted in recent have exclusively evaluated the store-and-forward method. This could be because the store-and-forward method is more flexible, costefficient, and therefore more attractive. 16 Nearly 90% of the patients used digital media, especially smartphones, in their daily business, but mostly for calls, and only 40% of them for video calls. Therefore, video consultation may be a problem for those patients. Nevertheless, even an older patient collective is capable and willing to use digital media as in our patient collective with a median age of 57 years.  how and for what they would use digital media in the future: the majority would use it for follow-up consultations and follow-up visits, so it would not be used by a majority for acute problems.
In conclusion, medical management using telephone consultations may be beneficial for prescription issues, as well as time-related and spatial barriers. The results underline the importance that telephone consultations should be further integrated in the German legislation to diminish barriers for reimbursement and legal liability.
The option of digital treatment is a promising future alternative, at least as an additional consultation option for patients with chronic diseases. The present study shows that teledermatology using telephone consultations is a useful add-on consultation method in times of the COVID-19 pandemic, but further research is needed to determine the long-term satisfaction, feasibility, and effectiveness of real-time teledermatology.

ACK N OWLED G M ENT
None.

CO N FLI C T O F I NTE R E S T
None declared.