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Figure 1.  Differential Diagnoses and Concordance
Differential Diagnoses and Concordance

The mention of differential diagnosis is inversely associated with diagnostic concordance. The graph shows the distribution of all cases with concordant and discordant diagnosis divided into those with and without mention of differential diagnosis. Data are plotted for both online and physical consultations together for clarity’s sake, with both kinds of consultations showing a clear association (online differentials, χ2P = .001; consultation differentials, χ2P < .001).

Figure 2.  Type of Physician Contact and Diagnostic Concordance
Type of Physician Contact and Diagnostic Concordance

The type of previous physician contact is associated with discordance of diagnosis between online and physical consultation. Previous physician contacts were categorized as no physician contact, contact with a general practitioner only, a dermatologist only, both a general practitioner and a dermatologist, more than 1 dermatologist, and with another specialist. Data are shown for 80 patients; data were missing for 8 patients (χ2P = .02).

Research Letter
December 2015

The Accuracy of Diagnosis of an Online Consultation Service Compared With Physical Consultation With a Dermatologist

Author Affiliations
  • 1Department of Dermatology, University Hospital Zürich, Zürich, Switzerland
  • 2Department of Clinical Telemedicine, University Hospital Zürich, Zürich, Switzerland
JAMA Dermatol. 2015;151(12):1375-1376. doi:10.1001/jamadermatol.2015.2537

The division of Clinical Telemedicine at University Hospital Zürich in Switzerland has run an email-based online consultation service for laymen since 1999, offering a physical consultation when deemed appropriate.1 We compared the adequacy of online diagnosis with the benchmark of an in-person dermatological consultation.


A retrospective review was performed for inquiries from June 2007 through September 2013. Paired online and physical consultations with a dermatologist after referral were included after institutional review board approval (NCT01969422). The institutional review board requested that patients be informed about a right to veto, which none exercised. Diagnoses were classified according to the dermatological diagnostic index developed by the German Dermatological Society DDG expanding the classifications of the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision.2 Concordance was defined as a matching of digits of the index code, resulting in 6 groups. IBM SPSS 22 software was used for descriptive statistics, χ2, and Kendall τ. P < .05 was considered significant.


One hundred two submissions (32 with photographs) were referred for dermatological consultation. A total of 88 patients presented, and 82 patients (median [SD] age, 38 [17] years, 41 [50%] male) were included. Diagnostic concordance was evenly distributed from low to high (χ2P = .16). A lack of differentials online (χ2P = .001), as well as on physical consultation (χ2P < .001), was associated with diagnostic concordance (Figure 1), but neither photograph submission, prediagnosed conditions, nor personal or family history information was significant (Kendall τ P = .80, P = .04, P = .30, P = .16, respectively). The kind of physician contact was associated with diagnostic concordance (χ2P = .02) (Figure 2). In 37 cases (42%), a second diagnosis was made at physical consultation.

The online and physical consultation diagnoses were concordant in 52% (n = 43, missing data n = 6) and enlarged concordant in 66% (n = 54, missing data n = 6). The patients’ dermatological problems were complex (53 [60%] had already visited a physician). Other studies show concordance or enlarged concordance rates from 47% to 89%, while a concordance rate greater than 60% is deemed reliable in teledermatology.3-6


Previous physician contact was not associated with diagnostic concordance except in cases in which more than 1 dermatologist or another specialist was visited. None of the information provided by users was associated with diagnostic concordance. Other studies did not look at this association of information provided and diagnostic concordance, but reported that a thorough history as such increases diagnostic concordance for clinical photographs from 57% to 70%.4-6 We noted absence of differential diagnosis as a factor in diagnostic confidence in both online (χ2P = .001) and physical consultation (P < .001).4,5 In 37 cases (42%), a second diagnosis was made during the physical consultation, with 1 basal cell and 1 squamous epithelial carcinoma diagnosed at consultation. The limitations of our study include its retrospective design, lack of randomization, and the limited patient numbers.

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Article Information

Accepted for Publication: June 19, 2015.

Corresponding Author: Günther F. L. Hofbauer, MD, Dermatologische Klinik, Universitätsspital Zürich, Gloriastrasse 31, 8091 Zürich, Switzerland (

Published Online: September 16, 2015. doi:10.1001/jamadermatol.2015.2537.

Author Contributions: Ms Grünig and Dr Hofbauer had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Ms Grünig and Dr Schmidt-Weitmann served as co–first authors, each with equal contribution to the manuscript. Drs Brockes-Bracht and Hofbauer served as co–last authors, each with equal contribution to the manuscript.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: Grünig, Brockes-Bracht, Hofbauer.

Drafting of the manuscript: Grünig, Brockes-Bracht, Hofbauer.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Grünig.

Obtained funding: Brockes-Bracht, Hofbauer.

Administrative, technical, or material support: Brockes-Bracht, Hofbauer.

Study supervision: Schmidt-Weitmann, Brockes-Bracht, Hofbauer.

Conflict of Interest Disclosures: None reported.

Hofbauer  GF, Bühler  RP, French  LE, Brockes  M, Scheuer  E.  Patient-centered care in dermatology: an online system that provides accessible and appropriate information to guide patients’ decision making.  Arch Dermatol. 2008;144(9):1225-1227.PubMedGoogle ScholarCrossref
Henseler  T, Weichenthal  M.  Dermatologischer Diagnosenkatalog mit ICD-10-Schlüssel. Ambulante Versorgung. Bern, Switzerland; Göttingen, Germany; Toronto, Ontario, Canada; and Seattle, WA: Verlag Hans Huber; 2002.
Romero  G, Cortina  P, Vera  E.  Telemedicine and teledermatology (II): current state of research on dermatology teleconsultations [in Spanish].  Actas Dermosifiliogr. 2008;99(8):586-597.PubMedGoogle ScholarCrossref
Lesher  JL  Jr, Davis  LS, Gourdin  FW, English  D, Thompson  WO.  Telemedicine evaluation of cutaneous diseases: a blinded comparative study.  J Am Acad Dermatol. 1998;38(1):27-31.PubMedGoogle ScholarCrossref
Pak  HS, Harden  D, Cruess  D, Welch  ML, Poropatich  R; National Capital Area Teledermatology Consortium.  Teledermatology: an intraobserver diagnostic correlation study, part II.  Cutis. 2003;71(6):476-480.PubMedGoogle Scholar
Whited  JD, Hall  RP, Simel  DL,  et al.  Reliability and accuracy of dermatologists’ clinic-based and digital image consultations.  J Am Acad Dermatol. 1999;41(5, pt 1):693-702.PubMedGoogle ScholarCrossref