RESEARCH/Original Article

Journal of Telemedicine and Telecare

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A systematic review of satisfaction ! The Author(s) 2017
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DOI: 10.1177/1357633X17696587
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Jessica S Mounessa1, Stephanie Chapman2, Taylor Braunberger3,

Rosie Qin4, Jules B Lipoff7, Robert P Dellavalle1,5,6 and
Cory A Dunnick1,5

Abstract
Background: The two most commonly used modalities of teledermatology (TD) are store-and-forward (SF) and live–
interactive (LI) TD. Existing studies have not compared these tools with respect to patient and provider satisfaction.
Objective: To systematically review all published studies of patient and provider satisfaction with SF and LI TD.
Methods: PubMed, EMBASE, and Cochrane databases were systematically searched for studies on provider or patient satis-
faction with SF or LI TD between January 2000 and June 2016.
Results: Forty eligible studies were identified: 32 with SF TD, 10 with LI TD, and 2 evaluating both. With SF TD, 96% of studies
assessing patient satisfaction and 82% of studies assessing provider satisfaction demonstrated satisfaction (n ¼ 24 and 17,
respectively). With LI TD, 89% of studies assessing patient satisfaction and all studies assessing provider satisfaction revealed
satisfaction (n ¼ 9 and 6, respectively).
Conclusion: Patients and providers are satisfied with both SF and LI TD. Studies assessing satisfaction with LI have not been
conducted in recent years, and have only been conducted in limited geographic patient populations. Further research assessing
satisfaction with TD will help address any dissatisfaction with its uses and allow for increased support and funding of future
programmes.
Keywords
eHealth, remote consultation, teleconsulting, teledermatology, telemedicine

Date received: 1 December 2016; Date accepted: 6 January 2017

Introduction Methods
Teledermatology (TD) consists of the delivery of dermato- Peer-reviewed journals listed on the PubMed (MEDLINE),
logic care from a distance using technology such as digital EMBASE, and Cochrane Library databases were searched
photography or video. The service allows physicians to for articles studying patient or physician satisfaction with
evaluate patients without an in-person appointment, and
its use has been increasing in recent years.1,2 Two widely
1
used models of the service include store-and-forward (SF) Department of Dermatology, University of Colorado Anschutz Medical
Campus, Aurora, CO, USA
and real-time or live–interactive (LI) TD.1,3 SF involves 2
Michigan State University College of Human Medicine, Grand Rapids, MI,
asynchronous sharing of patient photographs, whereas LI USA
uses synchronous videoconferencing. Advantages of SF 3
University of North Dakota School of Medicine, Grand Forks, ND, USA
4
include flexibility for consulting dermatologists and low Duke University School of Medicine, Durham, NC, USA
5
cost.4 Without instantaneous feedback, however, it can Dermatology Service, Eastern Colorado Health Care System, US
Department of Veteran Affairs, Denver, CO, USA
lead to delays in care.2 In contrast, LI provides instantan- 6
Department of Community and Behavioral Health, Colorado School of
eous feedback, but it lacks flexibility and may have greater Public Health, Aurora, CO, USA
technological requirements.2 The general trend has been an 7
Department of Dermatology, University of Pennsylvania Perelman School of
increase in use of SF systems and decrease in LI systems.5 Medicine, Philadelphia, PA, USA
Regardless of the model of delivery for TD, satisfaction
with the method of care is paramount to successful imple- Corresponding author:
Cory A Dunnick, Dermatology Service, Eastern Colorado Health Care
mentation. The primary aim of this study was to system- System, US Department of Veteran Affairs, 1665 Aurora Ct, Denver, CO
atically review published assessments of patient and 80045, USA.
provider satisfaction with SF and LI models. Email: [email protected]
2 Journal of Telemedicine and Telecare 0(0)

TD between January 2000 and June 2016. The following standardized criteria was developed to categorize studies
search terms were applied: (‘teledermatology’ AND into one of the two categories. We employed a cut-off
‘patient satisfaction’) OR (‘teledermatology’ AND ‘phys- score of at least 80% to demonstrate participant satisfac-
ician satisfaction’) OR (‘teledermatology’ AND ‘provider tion, as defined in Table 5 in the Appendix. The overall
satisfaction’) OR (‘teledermatology’ AND ‘user satisfac- quality of evidence for each article was determined using
tion’) OR (‘teledermatology’ AND ‘patient acceptance’) an abridged version of the rating scheme provided by the
OR (‘teledermatology’ AND ‘physician acceptance’) OR Oxford Center for Evidence-Based Medicine.6
(‘teledermatology’ AND ‘provider acceptance’) OR (‘tele-
dermatology’ AND ‘user acceptance’).
Results
Two reviewers independently screened all articles by title
and abstract. Exclusion criteria included articles not pub- A total of 197 articles were identified with PubMed
lished in English. Inclusion criteria were articles with quan- (n ¼ 75), EMBASE (n ¼ 112), and Cochrane Library
titative data evaluating patient or provider satisfaction or (n ¼ 10). After removing 77 duplicates, 120 articles were
acceptance with TD. Providers were further categorized screened for relevance, and 49 articles were excluded.
into referring providers (primary care physicians (PCPs), A search of 71 potentially relevant full-length articles
nurse practitioners, physician’s assistants, or nurses) vs. was conducted. Thirty-one additional articles were then
consulting dermatologists. Data collected from each study excluded: 9 articles were not available in full-text or in
included: country of origin, patient demographics, provider English, 11 did not quantify satisfaction, and 11 were
type, study method, type of TD (SF vs. LI), number of redundant with previous research. Forty publications
respondents, and measure of satisfaction. met all inclusion criteria (Figure 1).
Studies were categorized into those that demonstrated Of the 40 studies investigated, 33 studies assessed
satisfaction and those that did not. Because the studies either patient or provider satisfaction with SF TD. Eleven
varied in how satisfaction was reported, a set of of these studies (28%) originated in the United States.

Figure 1. Literature search. A total of 40 articles were included.

Mounessa 3

Table 1. Patient satisfaction with store-and-forward teledermatology.

Study
Quality demonstrates N
Country Authors Year of evidencea Outcome measure(s) satisfaction Respondents

Australia Horsham et al.7 M 2016 XSS, 4 Willingness to use again Yes 49

Austria Hofmann-Wellenhof 2006 CSS, 4 Overall satisfaction Yes 14
et al.25
Ebner et al. 26 M 2008 XSS, 4 Overall satisfaction Yes 48
Koller et al.27 M 2011 CSS, 4 Overall satisfaction, willingness Yes 17
to recommend TD
Fruhauf et al.20 P,M
2012 XSS, 4 Satisfaction with the accuracy Yes 10
and reliability of TD
Fruhauf et al.19 M
2015 RCT, 1 Overall acceptance Yes 24
Botswana Azfar et al.21 M 2011 XSS 4 Treatment and quality of care Yes 75
was equivalent to FTF
Colombia Ruiz et al.22 P
2009 CSS, 4 Satisfaction with understanding Yes 73
of information, quality of
healthcare service, and
duration
England Williams et al.23 2001 CSS, 4 Overall satisfaction Yes 123
Bowns et al.24 P 2006 XSS, 4 Satisfaction with skin condition Yes 66
management, satisfaction with
care received
Livingstone and 2015 ROS, 3 Overall satisfaction Yes 129
Solomon17
Ford et al.18 M 2016 PCS, 2 Overall satisfaction Yes 28
Israel Klaz et al.28 P 2005 PCS, 2 Overall satisfaction Yes 386
Netherlands Eminovic et al.30 2006 CSS, 4 Overall thoughts about TD Yes 84
Eminovic et al.29 2009 RCT, 1 Overall satisfaction Yes 191
Saudi Arabia Kaliyadan et al.31 M 2013 CSS, 4 Overall satisfaction Yes 143
Scotland Thind et al.10 2011 CCS, 3 Overall satisfaction Yes 31
USA Kvedar et al.11 P 1999 CSS, 4 Overall satisfaction Yes 18
Weinstock et al.12 P 2002 XSS, 4 Overall satisfaction No 100
McKoy et al.13 P 2004 CSS, 4 Comfort with remote diagnosis Yes 51
Lopez et al.14 L 2005 XSS, 4 Overall satisfaction Yes 13
Binder et al.15 P 2007 CSS, 4 Overall satisfaction Yes 16
Hsueh et al.16 2010 CSS, 4 Overall satisfaction Yes 501
Whited et al.9 2013 RCT, 1 Overall satisfaction Yes 93
Abbreviations: FTF ¼ face-to-face, TD ¼ teledermatology, RCT ¼randomized clinical trial, NRCT ¼ non-randomized clinical trial, CSS ¼ case-series study,
ROS ¼ retrospective observational study, CCS ¼ case-control study, PCS ¼ prospective comparative study, XSS ¼ cross-sectional study.
Notes: PStudy also reported provider satisfaction.
L
Study also involved live–interactive TD.
M
Mobile device used.
a
Evidence quality rating for overall study design. 1 is a properly powered RCT or systematic review with meta–analysis; 2 is a well-designed controlled trial
without randomization, prospective study, or comparative cohort trial; 3 is a case-control study or retrospective cohort study; and 4 is a case-series or cross
sectional study.

Other studies originated from Austria, England, the providers.36,42 Five studies assessed both patient and pro-
Netherlands, and Australia (n ¼ 5, n ¼ 4, n ¼ 3, and n ¼ 2, vider satisfaction with LI TD. The largest number of stu-
respectively). Studies revealed dissatisfaction with SF TD in dies was conducted in the United States (n ¼ 3), and one
1 of 24 studies assessing patients and 3 of 17 studies assess- study was conducted in each of these other countries:
ing providers (Tables 1 and 2).7–39 Eight of these studies India, England, New Zealand, Norway, South Africa,
assessed both patient and provider satisfaction with SF. Jordan, and Spain. Of the nine studies assessing patient
Nine studies on patient satisfaction and six studies on satisfaction with LI TD, one demonstrated dissatisfaction
provider satisfaction with LI TD were reviewed (Tables 3 (11%). No studies assessing provider satisfaction demon-
and 4).36,40–47 Two of these studies queried non-physician strated dissatisfaction.
4 Journal of Telemedicine and Telecare 0(0)

Table 2. Provider satisfaction with store-and-forward teledermatology.

Study
Quality N respondents demonstrates
Country Author Year of evidence Outcome measure(s) (type of provider) satisfaction

Australia Ou et al.32 2008 XSS, 4 Usefulness of TD 9 referring PCPs Yes

Austria Fruhauf et al.20 M,P
2012 XSS, 4 Acceptance 2 consulting dermatologists Yes
Colombia Ruiz et al.22 P 2009 CSS, 4 Overall satisfaction 6 consulting resident Yes
dermatologists
England Bowns et al.24 P
2006 RCT, 1 Overall satisfaction 36 referring PCPs No
2 consulting dermatologists No
India Rajagopal et al.36 B 2009 PCS, 2 Overall satisfaction – referring medical officers Yes
Israel Klaz et al.28 P 2005 PCS, 2 Overall satisfaction 397 referring PCPs Yes
Netherlands Van der 2010 CSS, 4 Overall satisfaction 18 consulting dermatologists Yes
Heijden et al.37
Singapore Janardhanan et al.38 2008 CSS, 4 Willingness to 5 referring nurses Yes
recommend
Spain Orruño39 2011 XSS, 4 Usefulness, ease of use, 135 referring PCPs and No
intent to use again, paediatricians, 26 consult-
attitude ing dermatologists
(assessed together)
USA Kvedar et al.11 P
1999 CSS, 4 Willingness to continue 12 referring PCPs Yes
using
Weinstock et al.12 P
2002 XSS, 4 Overall satisfaction 19 referring PCPs, PAs, NPs Yes
McKoy et al.13 P 2004 CSS, 4 Overall satisfaction 45 referring PCPs Yes
Whited et al.9 2004 RCT, 1 Overall satisfaction 38 referring PCPs, PAs, NPs Yes
8 consulting dermatologists Yes
Binder et al.15 P 2007 CSS, 4 Overall satisfaction 7 referring home care nurses Yes
McFarland et al.34 2013 XSS, 4 Overall satisfaction 21 referring PCPs Yes
Barbieri et al.35 2015 XSS, 4 TD increases access to 18 referring PCPs Yes
dermatologic care
TD improves patient Yes
care
Acceptability of TD Yes
Ogbechie et al.6 2015 XSS, 4 Interest in reusing TD 97 referring PCPs Yes
48 consulting dermatologists No
Abbreviations: FTF ¼ face-to-face, NP ¼ nurse practitioner, PA ¼ physician’s assistant, PCP ¼ primary care physician, TD ¼ teledermatology.
Notes: PStudy also reported patient satisfaction.
B
Study assessed both live–interactive and store-and-forward TD.
M
Mobile device used.

Discussion convenient to use.22 In terms of LI TD, patients in

This review reveals high levels of patient and provider Lowitt et al.’s study felt LI TD was similar to in-person
satisfaction with both SF and LI TD. While the finding consultation and saved them time.47 Consulting derma-
that patients may possess more positive views regarding tologists expressed satisfaction with the interpersonal
telecare when compared to their providers has been aspect of LI TD, high visual resolution of the video, and
reported in the literature,48 our study does not reveal a ability to examine necessary anatomic areas.47 LI TD pro-
gap in satisfaction levels between these groups. vides the benefit of allowing patients to ask questions and
Teledermatology serves as an effective visual tool that have providers clarify concerns in real time.
embraces new technology. At the same time, several concerns with the service were
Studies discuss numerous drivers of satisfaction with highlighted in the studies that did not demonstrate satis-
both SF and LI. In Ruiz et al.’s Colombian study on SF faction. In terms of SF TD, patient concerns highlighted
TD,22 patients expressed satisfaction with time duration, by Weinstock et al. included inadequate provider-patient
understanding of information, and quality of healthcare relationship, long wait time to schedule appointments and
service. Physicians felt the service was feasible and receive follow up care, inconsistencies in follow up, and
Mounessa 5

Table 3. Patient satisfaction with live–interactive teledermatology.

Study
Quality demonstrates N
Country Authors Year of evidence Outcome measure(s) satisfaction respondents

England Gilmour et al.40 P

1998 NRCT, 2 Preference of TD to normal No 122
consult
Jordan Al Quran et al.44 2015 CSS, 4 Overall satisfaction Yes 88
New Zealand Oakley et al.42 P 2004 CSS, 4 Willingness to use TD again Yes 20
Norway Nordal et al.43 P 2001 CCS, 3 Overall satisfaction Yes 116
South Africa Mars and Dlova45 P 2008 CSS, 4 Overall satisfaction Yes 69
Spain Artiles-Sanchez et al.46 2004 XSS, 4 Preference to see TD or wait, Yes 20
willingness to recommend TD
to a friend
USA Lowitt et al.47 P
1998 CCS, 3 Satisfaction with the exam and Yes 131
comfort talking with the
doctor
Hicks et al.41 2003 CSS, 4 Overall satisfaction Yes 258
Lopez et al.14 B
2005 XSS, 4 Overall satisfaction Yes 13
Abbreviations: TD ¼ teledermatology.
Notes: PStudy also reported patient satisfaction.
B
Study assessed both live–interactive and store-and-forward TD.
M
Mobile device used.

Table 4. Provider satisfaction with live–interactive teledermatology.

Study
Quality N respondents demonstrates
Country Author Year of evidence Outcome measure(s) used (type of provider) satisfaction

India Rajagopal et al.36 B 2009 PCS, 2 Overall satisfaction n/a referring Yes
England Gilmour et al.40 P 1998 NRCT, 2 TD’s educational benefit, value, 27 referring PCPs Yes
and ability to allow for a
satisfactory response
New Zealand Oakley et al.42 P
2004 CSS, 4 Ability of TD to provide educa- 4 referring PCPs and nurse Yes
tional and professional benefits
Norway Nordal et al.43 P
2001 CCS, 3 Feeling of contact with patient, 2 consulting dermatologists Yes
impression of the patient’s
confidence in provider, under-
standing of the patient’s
problem
South Africa Mars and Dlova45 P
2008 CSS, 4 Overall satisfaction 1 referring physician, 2 consult- Yes
ing dermatologists (assessed
together)
USA Lowitt et al.47 P
1998 CCS, 3 Satisfaction with ability to 4 consulting resident and Yes
examine skin attending dermatologists
Confidence with the diagnosis Yes
Abbreviations: FTF ¼ face-to-face, PCP ¼ primary care physician, TD ¼ teledermatology.
Notes: PStudy also reported patient satisfaction.
B
Study assessed both live–interactive and store-and-forward TD.

lack of explanation regarding their diagnosis or treatment the inability for the service to meet the demands of the
plan.12 The authors mentioned that complaints regarding patients.12 In contrast, Bowns et al.’s 2006 UK study
the provider-patient relationship often stemmed from eld- revealed that while patients were generally satisfied with
erly patients. Referring physicians, nurse practitioners, SF TD, both referring physicians and consulting derma-
and physician assistants reported positive experiences tologists had several concerns.24 These included the time
with the service, with their concerns mainly focusing on consuming nature of the service, increased workload
6 Journal of Telemedicine and Telecare 0(0)

involved, and technological complications experienced.24 patient or provider satisfaction. To standardize responses
A recent study further identified higher levels of satisfac- reporting satisfaction, we generated a point scale to apply
tion with TD among referring PCPs than consulting to all studies (see Appendix, Table 5). Second, the major-
dermatologists. Dermatologists reported concern with ity of studies assessing patient or provider satisfaction
liability, financial reimbursement, and diagnostic reliabil- with LI TD were over 10 years old, and therefore may
ity of the tool.8 no longer represent the current view of TD among
In terms of LI TD, only 38% of 122 patients in Gilmour patients and providers, especially in an age of rapid
et al.’s 1998 study preferred teleconsultation as compared technological advancement. Finally, because we did not
to a normal consultation.40 While this finding was not fully perform a meta-analysis of the studies, the potential for
explained, the technology was recently introduced at the publication bias exists.
time that the study was conducted, and numerous patients
expressed discomfort and embarrassment with the video-
conferencing.40 Our systematic review reveals that the
Conclusions
majority of studies evaluating patient or provider satisfac- This systematic review demonstrates that high levels of
tion with LI TD were performed more than 10 years ago, satisfaction with both store-and-forward and live–inter-
with the greatest number of studies peaking between 1997 active TD exist among patients, referring providers, and
and 2001. Consistent with this, a recent study suggested teledermatologists alike. Studies assessing satisfaction
that the use of LI TD has decreased in recent years, with the service have mainly occurred in developed coun-
likely because SF TD provides increased time efficiency tries. More recent studies of satisfaction among users
for the provider.49 An updated assessment of LI TD worldwide are required as this method of care expands
would be informative, especially given new developments in use and technology continues to evolve.
in technology. For example, a recent Japanese study
assessed asymmetric digital subscriber line (DSL)-based Declaration of Conflicting Interests
TD, which employs copper telephone lines instead of the The authors declared no potential conflicts of interest with
conventional voice band modem. The newly developed respect to the research, authorship, and/or publication of this
device was easy to manoeuvre and achieved high-resolution article.
images at an increased speed. The authors note that the
device is particularly cost efficient in rural hospitals that Funding
have limited access to live dermatologists.50 The authors received no financial support for the research,
Our study further identifies a need for additional authorship, and/or publication of this article.
research on satisfaction with TD in developing countries.
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