Quality and Perceived Usefulness of Patient-Submitted Store-and-Forward Teledermatology Images

Question  What is the quality and perceived usefulness of patient-submitted dermatology images?

Findings  In this survey study, 10 dermatologists found patient-submitted images useful for decision-making and sufficient in quality 55.1% and 62.2% of the time, respectively. Interrater agreement was fair to substantial for diagnostic categorization and fair to moderate for image quality and perceived usefulness, and the odds that an image was considered useful for decision-making were highest when the image depicted a wound, was in focus, and the evaluator was a senior faculty member.

Meaning  A slight majority of patient-submitted images were of adequate quality and perceived usefulness; thus, in-focus images may be useful for wound surveillance when reviewed by experienced attending physicians.

Importance  Patient-submitted images vary considerably in quality and usefulness. Studies that characterize patient-submitted images in a real-life setting are lacking.

Objective  To evaluate the quality and perceived usefulness of patient-submitted images as determined by dermatologists and characterize agreement of their responses.

Design, Setting, and Participants  This survey study included patient images submitted to the Department of Dermatology at Duke University (Durham, North Carolina) between August 1, 2018, and December 31, 2019. From a total pool of 1200 images, 10 dermatologists evaluated 200 or 400 images each, with every image being evaluated by 3 dermatologists. Data analysis occurred during the year leading up to the article being written.

Main Outcomes and Measures  The primary outcomes were the responses to 2 questions and were analyzed using frequency counts and interrater agreement (Fleiss κ) to assess image quality and perceived usefulness. We performed a random-effects logistic regression model to investigate factors associated with evaluators’ decision-making comfort. We hypothesized that most images would be of low quality and perceived usefulness, and that interrater agreement would be poor.

Results  A total of 259 of 2915 patient-submitted images (8.9%) did not depict a skin condition at all. The final analysis comprised 3600 unique image evaluations. Dermatologist evaluators indicated that 1985 images (55.1%) were useful for medical decision-making and 2239 (62.2%) were of sufficient quality. Interrater agreement for a given image’s diagnostic categorization was fair to substantial (κ range, 0.36-0.64), while agreement on image quality (κ range, 0.35-0.47) and perceived usefulness (κ range, 0.29-0.38) were fair to moderate. Senior faculty had higher odds of feeling comfortable with medical decision-making than junior faculty (odds ratio [OR], 3.68; 95% CI, 2.9-4.66; P < .001) and residents (OR, 5.55; 95% CI, 4.38-7.04; P < .001). Images depicting wounds (OR, 1.75; 95% CI, 1.18-2.58; P = .01) compared with inflammatory skin conditions and that were in focus (OR, 5.56; 95% CI, 4.63-6.67; P < .001) had higher odds of being considered useful for decision-making.

Conclusions and Relevance  In this survey study including 10 dermatologists, a slight majority of patient-submitted images were judged to be of adequate quality and perceived usefulness. Fair agreement between dermatologists was found regarding image quality and perceived usefulness, suggesting that store-and-forward teledermatology initiatives should consider a physician’s individual experiences and comfort level. The study results suggest that images are most likely to be useful when they are in focus and reviewed by experienced attending physicians for wound surveillance, but dermatologists may be burdened by irrelevant or unsuitable images.