by Derek S Leslie, Service Standards Manager, Highland Health Board

Telemedicine has been defined “as the application of modern telecommunications technology to medicine....” and is not in itself a new concept. Medical opinion by correspondence, by radio link and by telephone or telegraphy are long-standing examples of the use of technology to exchange advice at a distance. Advances in technology permits these well established methods to be supplemented by visual communications to overcome distance and geographical barriers between the patient and a remote health care specialist. The technology has established the ability to have not only television type images for live diagnostic or therapeutic consultations but also to have still images such as CT scans, x-rays, microsopic slides transmitted in a matter of minutes or less.

The practical use of this technology has been explored in a project, funded by Highland Health Board, against the background of two of the basic principles set out in the Highland Health Board strategy: that patients should be treated as close to their own homes as possible and that specialist medical expertise should be equally available irrespective of where the patient lives.

The Highland project involved the use of desktop video- conferencing equipment, a remote control video camera and viewing screens to ensure that the image presented is of an adequate quality to allow the specialist to offer a clinical diagnosis of the patient’s condition and to advise the General Practioner, who is with the patient throughout the consultation, on the appropriate treatment. The transfer of the image makes use of the British Telecom Integrated Services Digital Network (ISDN) facility established recently to provide high speed dial-up communications throughout the Highlands and Islands and beyond.

The principle focus of the project was a weekly teledermatology consultation session linking General Practioners and patients in Portree, Isle of Skye, to the Consultant Dermatologist in Raigmore Hospital, Inverness, some one hundred and twenty miles distant.

As an offshoot of the teledermatology project the use of the technology was also explored in Portree in relation to nurse education and psychology consultations. X-ray image transference has also been trialed between Fort William and Inverness.

During the six months of the pilot 51 patients in the age range between 2 and 88 were offered teledermatology. This produced 23 different diagnoses. Of the total number consulted, 27 were discharged, 19 were reviewed at the outreach follow-up clinic at Portree and 5 were referred to Raigmore Hospital.

Satisfaction was expressed on the general quality of image, particularly of moles, pigmented naevi, seborrhoeic keratoses, orf, molluscum contagiosum and acne. However, rashes did not focus well, even psoriasis, with most of the poor pictures being of eczematous patients. In fact, one of the "tinea" patients was later rediagnosed as a discoid eczema at a follow-up clinic.

Generally speaking all concerned in the project - patients, G.Ps. and the consultant dermatologist - were satisfied with the results. None of the patients, from the very young to the very old, objected to the technique . This may have been because of the presence of a G.P. who was usually their own doctor. The G.Ps. also enjoyed the experience and quickly became adept at handling the equipment. They appreciated the direct teaching they received in the diagnosis management of their patients. The consultant dermatologist found it most difficult being remote from the patient thus making it harder to establish a satisfactory patient/doctor relationship.

The duration of the consultations were slightly longer than at a normal clinic where ten minutes is allocated to a new patient. Some of the G.Ps. practiced with the patient in order to obtain the best pictures before calling the consultant.

The preliminary conclusions are that the pilot proved that the technique was useful and patients can certainly be screened for subsequent referral to a traditional clinic. It has also improved communications between the consultant dermatologist and the small group of G.Ps. and their patients. The results are sufficiently encouraging to justify an expansion of the study. Indeed an invitation has been received from the Institute of Telemedicine and Telecare of the Queens University Belfast to participate in a multi-centre trial of teledermatology under the auspices of the National Health Services Research and Development programme and this is currently being pursued.