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Published in final edited form as: Curr Dermatol Rep. 2023 Sep 12;12(4):161–168. doi: 10.1007/s13671-023-00404-w

Patient and Clinician Satisfaction in Teledermatology: Key Factors for Successful Implementation

Yiwen Li 1,2, Anna Pulminskas 1,2, Olivia Collins 3, Salma de la Feld 2,3, Howa Yeung 2,3
PMCID: PMC10939000  NIHMSID: NIHMS1961764  PMID: 38495517

Abstract

Purpose of review

Teledermatology has emerged as a promising solution for remote dermatologic care, especially during COVID-19 pandemic. It improves access to care through information and communication technologies. This paper explores patient and clinician satisfaction in teledermatology.

Recent findings

Patient satisfaction encompasses various aspects, including future willingness, the quality of care, technical quality, and access to care. Clinician satisfaction is influenced by quality of care, implementation, technical aspects, clinician-patient rapport, and financial considerations. It is important to evaluate patient and clinician satisfaction in different teledermatology models, including store-and-forward, live interactive, and hybrid interactive approaches.

Summary

By evaluating satisfaction within different teledermatology models and addressing the factors that impact satisfaction, teledermatology can ensure high-quality care and promote positive outcomes. With proper implementation and ongoing evaluation, teledermatology has the potential to become a widely accepted and valuable component of dermatologic care, offering enhanced access to specialized services.

Keywords: Teledermatology, Patient Satisfaction, Clinician Satisfaction, Store-and-forward, Live interactive, Direct-to-Patient

Introduction

Teledermatology has emerged as a promising remote dermatologic care solution, leveraging information and communication technologies to enhance access to care [1]. With its growing popularity, understanding the significance of patient and clinician satisfaction is paramount to its success. Measuring satisfaction can help providers identify areas for improvement and address potential shortcomings, leading to more effective services tailored to the needs of both parties. Moreover, it ensures positive patient outcomes, widespread adoption, and better retention rates, ultimately increasing access to specialized dermatologic care.

Satisfaction in teledermatology can be measured in terms of patient and clinician satisfaction (Figure 1). Patient satisfaction encompasses several aspects, including future willingness, quality of care, technical quality, and access to care [2, 3]. Clinician satisfaction, on the other hand, refers to the dermatologist’s contentment with factors such as quality of care, implementation, technical aspects, clinician-patient rapport, and finance [2, 3]. This paper aims to review patient and clinician satisfaction within store-and-forward, live interactive, and hybrid teledermatology models.

Figure 1.

Figure 1.

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Patient and Clinician Satisfaction in Teledermatology

This Venn diagram outlines the key factors influencing patient and clinician satisfaction in teledermatology and highlights the shared and distinct aspects that contribute to their overall experience.

Formats of teledermatology

There are three primary formats of teledermatology: store-and-forward, live interactive, and hybrid [4]. Store-and-forward involves the transmission of digital images and clinical data from the patient to the dermatologist for diagnosis and treatment planning. The dermatologist reviews the images at a later time and provides a diagnosis and treatment plan [3]. Live interactive enables real-time interactions between patients and dermatologists through video conferencing. Hybrid combines the advantages of both store and forward and live interactive approaches, supporting both asynchronous and synchronous communication. In this format, the patient captures images of their skin lesion or rash and sends them to the dermatologist for review asynchronously. If further evaluation or treatment is required, a live interactive consultation may be scheduled to ensure comprehensive evaluation and treatment planning [3]. Furthermore, there is the concept of direct-to- patient teledermatology [5, 6], which allows individuals to access dermatological care and advice directly through online platforms or mobile applications, without the need for a referral from a primary care physician. Users can upload images or describe their skin concerns, which are then evaluated remotely by physicians and advanced practice providers for diagnoses, treatment recommendations, and, if necessary, medication prescriptions through virtual consultations.

Patient Satisfaction with Teledermatology

Patient satisfaction definitions remain varied in scientific literature. However, a review of several related studies yielded common contributing attributes for patient satisfaction in Teledermatology. These attributes encompass various domains, including future willingness, quality of care, technical quality, and access to care in regard to teledermatology utilization [2, 3, 7]. These domains collectively reflect patient satisfaction in Teledermatology. The high levels of patient satisfaction reported in published literature indicate that teledermatology is a highly effective and promising solution for providing remote dermatologic care and most patients are willing to utilize teledermatological services in the future.

Future Willingness

Future willingness can be regarded as an overarching gauge of patient satisfaction, encompassing their inclination to utilize telemedicine services in the future. The findings consistently indicate a high level of patient willingness to continue receiving teledermatology care. For example, 93%, 95%, and 82% of patients in the age group of 21–40, 41–65, and ≥66, respectively, indicated their readiness to utilize live- interactive teledermatology system again [8]. Future willingness to use dermatology services is often compared between virtual visits and in-person visits. Notably, 90% of patients in an Italian academic center indicated their intention to continue consulting the same dermatologists in the future, following their live interactive teledermatology appointment [9].

Future willingness to participate in teledermatology can be influenced by factors such as the type of encounter, the nature of the disease, and patient preference including privacy concerns. Recent studies shed light on patient attitudes towards telehealth, revealing that although a majority expressed openness to specific medical encounters, there can still be reservations. For example, 72% of surveyed patients expressed willingness to engage in telehealth for isotretinoin follow-up encounters, while 59% expressed the same for non-isotretinoin acne encounters at a large academic center Pediatric Clinic [10 •]. However, it is worth noting that despite this openness, many families still preferred in-person encounters to facilitate personal interaction, especially for conditions perceived as serious [10 •]. Furthermore, concerns that may impede future participation in teledermatology include privacy concerns. For instance, patients who are older and non-White race may be more concerned about privacy and information access which may impact future participation in live-interactive teledermatology [8 •].

These findings provide valuable insights into the significance of future willingness in teledermatology and highlight factors that influence patient preferences and decisions. Understanding these factors is fundamental for enhancing patient satisfaction, improving the delivery of teledermatology services, and addressing concerns to ensure the successful integration of remote dermatological care.

Quality of care

Patient satisfaction with the quality of care in teledermatology services is evaluated through three key aspects: overall satisfaction when compared to in-person visits, the effectiveness in addressing patient needs and treatment concerns, and the adequacy of physical examinations [9, 11, 12].

Overall, patient satisfaction with the quality of care in teledermatology services compared to in-person visits is found to be high. In the live interactive model, two studies yielded similar results, with over 90% of patients rating their teledermatology treatment experience as “good,” “very good,” or “excellent” in a study conducted in a major southeastern medical center [11]. Moreover, 71% of patients expressed acceptable quality of care with the live interactive teledermatology treatment they received, in a study conducted a large medical center in Italy [9]. In the direct-to-patient model, further investigations have examined the use of teledermatology services for follow-up visits after the initial dermatology appointment and showed high patient satisfaction with the quality of care they received. For example, in a study comparing treatment outcomes, acne patients who utilized an online platform to send follow-up images of their skin to dermatologists achieved a mean decrease of 6.67 inflammatory lesions. This is comparable to the 9.39 mean lesion reduction observed in those attending face-to-face appointments. The difference of 2.72 lesions between the two groups was considered clinically comparable. Additionally, patients reported comparable levels of satisfaction with the care provided, regardless of whether it was via store-and-forward teledermatology or face-to-face dermatology visits [13]. Moreover, in the context of mobile teledermatology for home monitoring of high-need patients with psoriasis, patients demonstrated a high level of satisfaction with the quality of care, considering an additional face-to-face follow-up unnecessary [14].

Effectiveness of addressing patient needs and/or treatment concerns are important measures of quality of care that influence patient satisfaction. In a live interactive model study conducted in a US medical center, 89% of patients felt that their dermatological treatment concerns were adequately addressed [12]. When comparing live interactive to in-person clinical encounters, more than 90% of patients also indicated that the quality of care was at least equal to in-person visits in terms of visit preparation, treatment plan, and follow-up from a US academic medical center study that surveyed patients’ teledermatology expectations and satisfaction [15].

Remote physical examination is one aspect of the quality of care that may be improved. Patients raised concerns regarding quality of care pertaining to the remote physical examination aspect of teledermatology care, specifically in the live interactive model. For example, 27% of patients expressed poor quality of care with the remote physical examination component, and 58% preferred an in-person physical examination over a remote visit [15 ••]. Additionally, 36% of patients found the remote physical exam provided “slightly worse quality of care”, and 15% mentioned the quality of care to be “much worse” in another study conducted at a medical center [16].

Technical quality

Technical quality can be measured by the overall ease of use and quality of images, videos, and audio. Ensuring technical quality is vital for delivering effective and satisfactory teledermatology services to patients.

The ease of use aspect of teledermatology directly impacts patient satisfaction. In live interactive model, two studies reviewed patient satisfaction on ease of use: 92% of patients “strongly agreed” or “agreed” that the MyChart App demonstrated ease of use for video visits in a study conducted at a US academic center [14]. Additionally, 84% of patients expressed ease in logging into a video system in a study conducted at another US academic center [16]. In direct-to-patient model, two studies examined patient satisfaction regarding the ease of use: 83% of participants experienced ease of use in a prospective evaluation of teledermatology app at a pediatric academic center [17]. Patients also reported technical convenience as the greatest benefit of the service, highlighting high levels of satisfaction and ease of use in a qualitative study on the implementation of Stanford Health Care’s direct-to- patient Teledermatology program [18].

The image, video, and audio technical quality of teledermatology consultations impact patient satisfaction with the live interactive model. For example, 90% of patients “strongly agreed” that the video and audio quality were of a good technical quality [14]. Similarly, more than 80% of patients rated the technical quality aspects of their teledermatology visits as “good”, “very good”, or “excellent”, and more than 90% expressed satisfaction with the audio and visual quality of the visits in a study conducted at a southeastern medical center [11]. Comparing pre- and post-consultation questionnaires, participants reported less audio and visual issues during teledermatology visits than anticipated in a study administered by a large academic center [8]. In fact, 78% of patients experienced no technological interruptions during live interactive teledermatology visits [16]. In the context of direct-to- patient service models, the quality of images provided by patients seeking dermatologic treatment at the Swiss Centre for Telemedicine was of an acceptable standard, as definitive diagnoses could be made in 67% of cases, and therapeutic recommendations could be formulated in 70% of cases [19].

Access to care

Teledermatology has increased patient access to dermatologic care, which in turn has a positive impact on patient satisfaction with teledermatology. The impacts of teledermatology may include reduced missed appointments and increased appointment capacity, decreased wait time to appointments, and reduced travel time.

Teledermatology increases access to care by reducing missed appointments and increasing appointment capacity. Missed appointments extend a backlog of patients who were referred for a dermatology consultation [20]. Implementation of teledermatology reduced the number of missed appointments in community health centers in underserved communities: the proportion of dermatology appointments kept by patients increased from 11% before teledermatology implementation to 44% after teledermatology implementation [21]. Teledermatology implementation also expands access to dermatologic care in resource-poor primary care settings: 61% of the participants in a resource-poor primary care setting who received store-and-forward teledermatology would otherwise not have received care from a dermatologist because their primary care physician would have selected to take care of the issue themselves or not treat the concern, if not for the implementation of store-and-forward teledermatology[22].

Wait times decreased due to increased availability of teledermatology during the pandemic [23]. The wait time for a dermatology appointment following a referral decreased from 26.8 days for an in-person appointment to 14.3 days for a store-and-video teledermatology appointment at a large group dermatology practice. As a result, patient access to dermatologic care increased despite adverse factors such as low personal protective equipment, strict spacing guidelines, and patient fears of leaving the house during the early pandemic [24].

Long travel time to appointments creates a travel burden on patients, which negatively impacts access to care [25]. In a large academic center, 64% of patients reported time savings of over 1 hour with use of live-interactive teledermatology use [7 •]. For example, 93% of patients listed “ease and convenience”, 79% listed “no commute required” and 64% listed “more efficient/quick appointments” as reasons for choosing a teledermatology appointment over an in-person appointment for isotretinoin management in a large academic center [26]. Patients seeking Mohs surgery consultation in one VA hospital saved an average of 132 miles of commuting and an average of 152 minutes by opting for store-and-forward teledermatology [27].

Clinician Satisfaction with Teledermatology

Research into clinician satisfaction with teledermatology is an important endeavor. First, teledermatology boomed with the pandemic and is rapidly changing. Secondly, there are far fewer studies measuring factors that influence clinician satisfaction with teledermatology than patient satisfaction. With rapidly evolving teledermatology options as well as physicians being at the forefront of implementing these changes, it is imperative to assess clinician satisfaction. In this review, we summarize five factors that impact clinician satisfaction with teledermatology: quality of care, implementation, technical aspects, patient-clinician rapport, and finance. While clinician satisfaction varies with different types and aspects of teledermatology, clinicians do exhibit overall satisfaction [28–31] and most will likely keep utilizing teledermatology in the future [7, 28–36].

Quality of Care

Clinician satisfaction with teledermatology is impacted by the quality of care provided, which can be evaluated by diagnostic accuracy and varies among teledermatology models. For instance, 62% of clinicians surveyed by the American Academy of Dermatology (AAD) were satisfied with the quality of care provided via store-and-forward and live-interactive teledermatology during the pandemic [34]. Yet, another study published that same year found that 91% of clinicians in India were not satisfied with the quality of care delivered with a smartphone-based hybrid model of teledermatology due to difficulty in assessing morphology and topography of lesions [28]. While these two studies are providing contradictory conclusions, it is important to note that the types of skin conditions addressed in each study are unknown. In fact, the quality of care and diagnostic accuracy of teledermatology varies greatly by the skin condition treated. Nearly 100% of surveyed academic dermatologists reported that conditions such as acne, rosacea, psoriasis, and eczema could be managed either entirely by synchronous-video telemedicine alone or by telemedicine in conjunction with in-person visits. The same group reported that other conditions, such as hair loss and lesions of concern, could not be managed with synchronous-video teledermatology at all, or would require an in-person visit in addition to teledermatology [7]. Additionally, nearly all clinicians surveyed among three studies of academic dermatologists, the AAD, and the Association of Professors of Dermatology (APD), agree that total body skin exams were inappropriate to be conducted via teledermatology altogether [7, 33, 34]. While diagnostic accuracy varies with the condition being treated, overall teledermatology provides good diagnostic accuracy and therefore quality of care. For instance, 78% of inflammatory dermatoses and 81% of malignant vs. benign skin neoplasms were diagnosed correctly via store-and-forward teledermatology when compared to in-person visits among clinicians in a public health system in Brazil [37, 38]. Finally, while the type of skin condition treated greatly impacts the diagnostic accuracy of the teledermatology visit, the type of teledermatology platform used matters as well. In fact, 66% of clinicians surveyed by the APD agreed that the most acceptable teledermatology platform is the synchronous audio and video visit with stored digital photos, while only 17% considered telephone visits without stored digital photos to be an acceptable platform [33]. Thus, the quality of care provided via teledermatology varies both with the type of condition treated as well as the platform used.

Implementation

The implementation of teledermatology has expanded significantly during the pandemic due to changes from the US Centers for Medicare and Medicaid Services (CMS), which eliminated geographic location barriers and granted payment parity between in-person and teledermatology visits [39]. As a result, many dermatologists across both academic and non-academic settings used teledermatology during the pandemic [28–32, 40]. Only 14% of clinicians surveyed by the AAD used teledermatology prior to the pandemic, while 97% of the same clinicians used teledermatology during the pandemic [34]. Additionally, 69% of clinicians surveyed by the APD agreed to having sufficient teledermatology training, 57% agreed to having sufficient financial resources, and 20% agreed to have sufficient facilities to employ various modalities of teledermatology [33]. From the changes passed by the CMS, teledermatology became easier to implement during the pandemic, and has positively contributed to clinician satisfaction with teledermatology.

Technical Aspects

The technical aspects of teledermatology are two-fold: a successful teledermatology appointment requires both good technology quality (such as video, image, and audio quality) as well as user capability to use the technology. When looking at the technical quality aspect of teledermatology, many clinicians were dissatisfied: 53% of clinicians surveyed in India reported that technical or connectivity issues were a major difficulty when using live-interactive teledermatology [28]. More specifically, video and sound quality are of concern for live interactive modalities of teledermatology, and image quality is of concern to store-and-forward platforms. For instance, in live interactive teledermatology, only 37% of clinicians surveyed in an academic department agreed that picture and audio quality were good [7]. However, in a similar study conducted in France clinicians were satisfied with video quality. In fact, these clinicians ranked both the quality of internet connection and quality of sound as 9–10 out of 10 points for live-interactive teledermatology. In store-and-forward teledermatology, clinicians were less satisfied with image quality, ranking it at 6–7 out of 10 points [36]. While clinician satisfaction with video, audio, and image quality varies, a possible contributing factor can be the varying technical literacy of patients who are in charge of using technology, for instance taking pictures or connecting to a reliable internet network. In fact, 21% of clinicians surveyed among national academic dermatologists identified patient technical skills as a weakness for both synchronous and asynchronous teledermatology [30 ••]. While image, video, and audio quality may be controllable factors that impact clinician satisfaction, satisfaction is also impacted by the uncontrollable factor of patient technical literacy.

Patient-Clinician Rapport

Rapport-building between clinicians and patients is key for a successful visit. Effective communication is achieved both through a visit free of technical difficulties (discussed above) and through building rapport with patients. In fact, many clinicians agree that teledermatology poses a challenge to establishing rapport with patients: 79% of surveyed clinicians in India had trouble in establishing rapport during live interactive teledermatology visits[28]. It is important to mention that there is very limited data available regarding clinician satisfaction with building patient-clinician rapport during teledermatology visits. Further research should be pursued into the topic to determine the impact of effective patient communication on physician satisfaction with teledermatology.

Finance

Reimbursement for teledermatology is a key factor to consider when determining clinician satisfaction. Prior to the pandemic, store-and-foreword was the most utilized model of teledermatology, but since the pandemic, live interactive teledermatology model soared [41]. One contributing factor is likely CMS granting payment parity between in-person and teledermatology visits starting in June 2020 until 2023 [39]. Prior to this, clinicians felt that teledermatology provided low financial reimbursement for both live-interactive and store-and-forward teledermatology. In fact, 69% of physicians surveyed between May-June 2020 by the AAD felt that low reimbursement was a barrier to the implementation of live interactive teledermatology, and 85% of the clinicians felt that reimbursement for store-and-forward was too low [34 •]. After the passing of the payment parity between in-person and teledermatology visits, the use of teledermatology soared, as previously discussed. A major contributor to the wide use of teledermatology was increased reimbursement: 73% of the same group of clinicians surveyed above indicated that the improved reimbursement for live-interactive teledermatology during the pandemic played a role in their decision to practice teledermatology. In fact, 70% of these clinicians indicated that they will likely continue to employ teledermatology if payment parity remains [34]. Overall, clinicians are satisfied with the current financial reimbursement for teledermatology. However, given ongoing uncertainties about the future of telehealth reimbursement as the payment parity granted by the CMS is coming to an end, future studies are needed to understand how clinician satisfaction will be impacted by upcoming legislature changes [42].

Recommendation for Future Implementation

In this transformative era, where individuals have embraced teledermatology during the pandemic and experienced its benefits, our approach to sustaining teledermatology long-term should be forward-thinking. We have outlined a set of initiatives, drawing from reviewed literature and incorporating lessons learned from factors impacting patient and clinician satisfaction.

Enhancing patient technical literacy, ensuring access to high-quality technology, and establishing dedicated telehealth support are essential for teledermatology implementation [43]. Firstly, the development of comprehensive digital literacy programs in collaboration with community centers, libraries, and healthcare facilities would educate patients on the effective use of technology. These programs should offer workshops and training sessions covering basic computer skills, internet navigation, and relevant applications. Additionally, government investment in broadband infrastructure is crucial, particularly in rural areas, to improve internet connectivity and eliminate barriers to teledermatology services [44]. To bridge the digital divide, subsidized internet and computer access should be made available to underserved populations through partnerships with providers and manufacturers [45, 46]. For instance, affordable internet plans or low-cost refurbished computers can be offered to eligible individuals. Finally, establishing dedicated telehealth support hotlines, staffed with trained personnel, would assist patients in resolving technical issues and provide guidance on utilizing teledermatology platforms effectively.

Developing a clear understanding of the benefits and limitations of teledermatology services is important to ensure patient satisfaction. While a physical examination may not always be ideal in the live interactive model of teledermatology, alternative diagnostic methods and patient-provided images can assist in informing clinical decisions. Implementing a user-friendly system that enables patients to upload high-quality pictures of specific areas of concern, along with detailed clinical descriptions, can help overcome the limitations associated with the physical exam during videoconferencing [47]. It is essential to conduct thorough quality checks on the uploaded images to ensure their clarity and accuracy. Patients should be aware that teledermatology is not a comprehensive solution for all skin complaints, and some cases may require in-person visits for further evaluation or treatment. Additionally, triaging patients based on the nature and severity of their skin concerns can aid in determining the most appropriate mode of dermatological care delivery, optimizing the utilization of resources[48].

Building rapport with patients can be challenging in teledermatology. Clinicians should be mindful of their visual cues and body language, maintaining eye contact with the camera and using facial expressions to convey warmth and attentiveness [49 •]. Addressing patient concerns about the limitations of teledermatology openly and honestly, while providing reassurance and offering in-person visits when necessary, can further strengthen the patient-clinician relationship.

Fair reimbursement policies are essential for the successful integration of teledermatology into the healthcare system, incentivizing clinician participation, and maintaining high-quality care [50, 51]. When appropriately implemented, teledermatology has the potential to enhance access to healthcare services and expand the volume of care provided. Consequently, it becomes imperative to establish policies that adequately compensate clinicians and supporting staff for their provision of teledermatology services, thereby fostering their active engagement and upholding the quality of care delivered. Moreover, the adoption of teledermatology brings about additional advantages, such as reduced travel time for patients, resulting in cost savings for the healthcare system.

Conclusions

Identifying and assessing the factors contributing to patient and clinician satisfaction will be crucial for the continued success and acceptance of teledermatology. By understanding and addressing these important factors, we can ensure that teledermatology continues to provide accessible and high-quality care while maximizing patient satisfaction and outcomes. With proper policy support and a patient-centered approach, teledermatology has the potential to become an integral and invaluable component of dermatologic care, benefiting both patients and the healthcare system as a whole.

Funding sources:

Dr. Yeung was supported in part by National Center for Advancing Translational Sciences of the National Institutes of Health under award number UL1TR002378 and KL2TR002381 and by the National Institute of Arthritis and Musculoskeletal and Skin Diseasesunder award numbers L30AR076081 and K23AR075888. Ms. Collins, Dr. de la Feld, and Dr. Yeung are also supported in part by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Health Services Research and Development under award number I01HX003473. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or Department of Veterans Affairs.

Footnotes

Conflicts of Interest: None declared.

References

References with Bullet:

References marked as “Bullet important •”:

○ Reference #7: Highlights the benefits of teledermatology in terms of time and travel savings.

○ Reference #8: Highlights privacy concerns among non-white and older populations regarding the use of teledermatology.

○ Reference #10: Indicates that the type of encounter and the nature of the disease can influence patients’ future willingness to participate in teledermatology.

○ Reference #33: Emphasizes that fair reimbursement is an ongoing concern for the future of teledermatology.

Reference marked as “Bullet Very Important ••”

○ Reference #15: Points out the need for improvement in the physical examination aspect of live interactive teledermatology.

○ Reference #30: Emphasizes the importance of helping patients increase their technical literacy for the success of teledermatology.

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